Alan Benoy Insurance Services

 

Frequently Asked Questions

This is, by no means, an exhaustive list of FAQs. However, we hope you find its contents helpful as you seek to make an educated decision in your search for health insurance. If you'd like to view this as a PDF, click here.

I don't know a PPO from an HMO from an HSA. Which one is right for ME???!!! 

PPO (Preferred Provider Organization): A delivery system where providers are under contract to an insurance carrier to provide care at a discount or for a fixed fee, and the health plan provides incentives to patients to use contracting providers. The PPO does not assume insurance risk, and it does not facilitate the sharing of risk by its covered persons.

HMO (Health Maintenance Organization): An organization that provides a wide range of comprehensive health care services for a specified group at a fixed periodic payment; a prepaid health care plan under which people may enroll by paying a set annual fee. Members then received all the medical services they need through a group of contracting doctors and hospitals, often with no additional copayments or fees. Members are generally limited to using providers designated by the HMO. (Example: Kaiser Permanente)

HSA (Health Savings Account): Plan that allows you to contribute pre-tax money to be used for qualified medical expenses. HSAs, which are portable, must be linked to a high-deductible health insurance policy. An HSA can also be a PPO or an HMO.

Which One is Right for Me? Here’s where an agent comes in. There are a lot of plans to choose from. We’re available to help you decide which plan is right for you, so feel free to CONTACT US. We’ll help you through the process. You can always GET A QUOTE for multiple insurance plans and carriers to start.

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Will my plan cost less if I go directly through the insurance company instead of using an agent?

Rates are determined by the insurance company and will be exactly the same regardless of whether you obtain coverage through an agent or apply directly with an insurance carrier. So, the question is, do you want to talk to an agent when you have questions/concerns, or do you want to call an impersonal, 800 number and wait on hold for an indefinite period of time with the insurance carrier?

I'm SO CONFUSED! What's the difference between a Co-Pay, Deductible, Co-Insurance, Out-of-Pocket Max?

Co-Pay: The amount you pay for a specific service, as described in your plan’s Summary of Benefits. (Example:  a $25 co-pay for a regular office visit or a $100 co-pay for an ER visit) Co-pays are often “deductible waived,” meaning, you are not required to pay the entire deductible before you pay the co-pay. (This is a good thing.)

Deductible: An amount the covered person must pay before payments for covered services begin (except, of course, on “deductible waived” co-pays). The deductible is usually a fixed amount or a percentage determined by the individual’s contract, and is calculated based on the lower hospital/provider actual charges or payment benefit. For example, an insurance plan might require the insured to pay the first $5,000 of covered expense during a calendar year.

Co-Insurance: Once the deductible has been paid, the insured is required to pay the co-insurance percentage (example: 30%) of the insurance-negotiated rates (which is lower than if you were a cash-pay patient) until they have reached the out-of-pocket maximum for that calendar year.

Out-of-Pocket Maximum: This is the maximum amount of charges that a covered person will be required to pay for expenses covered under the plan. It is a sum of deductible and co-insurance amounts.

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How Long Does it Take to Get Approved?

Your application may take a few days to six weeks to be processed.  Three to five weeks is about normal.  Recent changes in the law prohibit coverage to become effective less than 15 days from the day the application was received by the carrier.

Can I be declined if I apply for individual/family coverage?

Yes.  Individual coverage is NOT guaranteed issue. 

Are there other options if I am declined? 

In many cases, yes.  Coverage under the California Major Risk Insurance Plan (MRMIP) or the state’s Pre-existing Insurance Plan (PCIP) may be available.  See these websites for additional information.

MRMIP: http://www.mrmib.ca.gov/MRMIB/MRMIP.shtml

PCIP: http://www.pcip.ca.gov/Home/default.aspx   

Can I appeal a decision if I’m rated or declined?  

There is an appeals process if you are rated or declined.   Once a decision has been reached by the underwriter, you will receive an “outcome letter” stating that you are either approved, rated or declined.  If you are rated or declined, you will be provided with a brief reason and a telephone number to call for additional information.  If you are not satisfied with the underwriter’s decision, you may request an appeal.  An appeals board is normally comprised of medical professionals that are not affiliated with the insurance company, which is designed to provide a greater level of objectivity.

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What about pre-existing conditions? 

Depending on the pre-existing condition and how it may affect future claims, the insurance carrier may offer you coverage at the standard rate, a higher rate, or decline coverage altogether.  In the state of California, carriers may not offer coverage and exclude certain pre-existing conditions. 

What if I’m pregnant? 

Carriers will not consider applicants for coverage while pregnant.  You may be eligible for assistance under a CA state program called A.I.M.  (See http://www.mrmib.ca.gov/MRMIB/AIM.shtml for details.)

What does it mean to be rated?  

Overall health factors may warrant a rating above the standard published rate.  These can include pre-existing conditions, prescription drugs, build, use of tobacco products, excessive alcohol usage, and previous health conditions. 

Generally speaking, carriers look for applicants to be symptom- and treatment-free for 6 to 12 months, depending on the condition.   Some conditions will be considered up to 10 years or more prior to the application date.  

Can I be cancelled? 

Once an application has been approved, an insurance company cannot cancel the policy.  If the applicant falsified or omitted information on their application, the policy may be rescinded from the date of issue.  From time to time, plans are discontinued, in which case the member would typically be transitioned to a different plan, or given the option of certain other plans.   

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How long are my rates guaranteed?

Typically, once you are approved, your rate will typically not change for 6 to 12 months.  Most carriers offer a one year rate guarantee.  An exception to this is at the change in age which would put them into a higher rate band, at which time the member’s rate is adjusted.  Once a member has been accepted, he/she would not be singled out for a rate increase due to health conditions.  Rates are adjusted for a given plan for all members of that plan.  There are many factors which enter into the need to increase rates; claims, overhead, legal and administrative expenses, legislative mandates, and the list goes on and on.   Rate increases must be approved by the State’s  Department of Insurance and/or the State agency governing the plan. 

Are children under age 19 guaranteed coverage? 

Typically yes, but there are some timeframes you need to be aware of.  See the following in regard to guaranteed coverage for minor children:

A child’s open enrollment period applies to each individual child during the month of the child’s birth date. In order to verify eligibility:

• Applications for open enrollment must be received during the child/children’s month of birth and should include proof of birth date such as a copy of the birth certificate, passport, or driver’s license.

• If prior coverage within the 90 day period prior to the date of the child/children’s application, please include a copy of the Certificate of Creditable Coverage or the premium billing statement showing coverage for the applicant.

• A child may be assessed a 20% surcharge for a period not greater than 12 months if the applicant has not had prior coverage within the 90 day period prior to the date of the child/children’s application and is not a late enrollee.

A child without coverage may qualify as a "late enrollee" if they did not enroll in coverage during an open enrollment for any of the following reasons:

• Loss of coverage due to termination or change in employment status of the child or person through whom child was covered

• Employer contribution for child’s coverage is terminated

• Death, legal separation, or divorce of the subscriber under which the child is covered

• Loss of access to Healthy Families, Access for Infants and Mothers, or Medi-Cal coverage

• Child moves to CA during a month that is not the child's birth month

• The child is mandated to be covered by a court order

• The child is within 63 Days from their date of birth or adoption

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What is COBRA? 

The short answer is that a law called the Consolidated Omnibus Budget Reconciliation Act, (aren’t you glad you asked?), or COBRA for short, gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102 percent of the cost to the plan.  

There is a lot to the COBRA law, so for additional information, check out:

http://www.dol.gov/dol/topic/health-plans/cobra.htm.

Typically, COBRA extends group coverage for up to 18 months.  Once COBRA is exhausted, an employee is often eligible for Cal-COBRA for an additional 18 months.  There are exceptions to this, so check with the plan or plan administrator to be sure.

What happens after my COBRA/Cal-COBRA benefits are exhausted?

If you can’t qualify for individual coverage, you may be able to transition to a guaranteed issue H.I.P.A.A. plan.  Check with your plan or plan administrator well in advance of the end date of your COBRA/Cal-COBRA plan for options. 

Are my annual physicals covered under my health plan?

Preventive services are covered under all plans.  There should not be a co-pay for preventive services.  We recommend that you ask your provider to confirm coverage with your health plan prior to your visit to make sure. 

Why do they call it a Health Plan instead of Health Insurance?

Yes, health plans used to be called health insurance plans.  Then, some Politian or bureaucrat had an epiphany, (defined as; a sudden, intuitive perception of or insight into the reality or essential meaning of something, usually initiated by some simple, homely, or commonplace occurrence or experience),  or a little too much to drink on night, or whatever, and now your health insurance plan is called a health plan.  Go figure.

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Go back to Individual/Family Home.   

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Dave Ramsey/FPU Experience

As a broker, we can offer a wide variety of individual and family health plans.  The recent Health Care Reform law expanded benefits to all health plans.

New provisions include:

• Preventive Care
• Dependent Coverage to Age 26
• No Lifetime Limits
• Guaranteed Issue to Children under 19 years of age

Contact us for help with your individual and family health plan needs today.

Coming off COBRA? See 5 Tips for Life after COBRA.