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Group Access would like to provide some useful information to help you with the terminology of the insurance industry.

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Useful Tips and Glossary

Useful tips and Terms:

Health insurance can be difficult to understand. Group Access, Inc would like for you to get the most out of your benefits. We have provided a few useful tips and a glossary to help you have a better understanding of your benefits. For more information on health, life and other types of insurance go to these web sites. (www.iii.org or www.ahip.org)

Medical Insurance Tips

As an insured you have rights and responsibilities

Rights – You have the right to…
… choose your own physician from the network
… accept or refuse medical treatment
… obtain information from your doctor to help in make decision for your best care
… have your medical information is kept private
… voice your concerns or ask questions about your care

Responsibilities – You have the responsibility to…
… insure that the provider you are seeking treatment from is in the network
… have your insurance card with you
… if you have concerns about a bill, call the insurance company and or the provider
… acquire information to be able to decide what will be your best medical care

What you can expect:

Your primary care physician should verify that the doctor he is referring you to is in the network but it is your responsibility as well to insure that they are in the network.
Suggestion: When you call to make your appointment ask them if they take your insurance and give them the information on the card so they can verify it.

Emergency visits to the Hospital, When are they covered? 55% of emergency room visits are not true emergencies. The emergency room visit is only for life or limb threatening situations; otherwise the insurance company will not pay. This can be very costly to the insured.
Suggestion: Use good judgment when deciding to go to the emergency room. Learn the symptoms that classify an emergency. When in doubt call your PCP and describe your symptoms. If it is after hours call the # on your card and the insurance carrier will refer you to the closest after hour’s facility in your area if it is not an emergency. (It will be quicker than going the emergency room if you are just feeling bad. The ER does not work on a first come first serve basis.)

• Some Symptoms of an Emergency
  1. Loss of consciousness
  2. Signs of a Heart Attack
  3. Signs of a Stroke
  4. Severe shortness of Breath
  5. A Severe Accident orBurn
  6. Head Trauma
  7. Severe or unusual bleeding that does not stop after 10 minutes of direct pressure
  8. Sudden Severe Pain
  9. Poisoning (If possible, call the poison control center. Someone can give advise to help the problem until emergence care can be given.)
  10. Coughing or vomiting blood
  11. A sudden severe reaction to insect bite or chemicals
  12. Broken Bones

Difference between individual and group health insurance

Group insurance is offered to employers and groups (unions, trade, and professional associations). The reason why group insurance is much more affordable to buy is due to the fact that insurance companies do not require evidence of insurability. Risk is spread among members with both good and bad health conditions. When trying to buy an individual health insurance policy, it is usually required to undergo a medical exam that provides the evidence of insurability. Insurance companies routinely deny coverage to individuals because of risk factors, some of which are not entirely based on the individual's medical history.

Dental Insurance Tips

1. Remember with most dental insurance you only have 2 cleanings per year that are covered at a 100%, if they are 6 months and 1 day apart. So schedule your appointment(s) accordingly.

2. Traditional dental insurance have a maximum benefit amount they will pay out per year. Most are $1000 per year, but there are a few that are higher. The max per year benefit is the most that an insurance company will pay out per year for all dental care work. Example: If you have more than $1000 a year in dental work, the insurance company will pay up to that amount and the overage is your expense.

3. Most dental plans have waiting period for particular procedures. They are put into categories or Type Procedures (Type I, Type II, Type III) Type I procedures usually have no waiting periods while type II and III can have 0 months to 12 months depending on your dental plan. This means that if you need any dental work that falls into on of these categories you may have to wait 12 months before the insurance company will pay any benefits towards that procedure.

Disability

DISABILITY INSURANCE
Disability can be more disastrous financially than death. If you are disabled, you lose your earning power. You still have living expenses and, often, huge expenses for medical care. When purchasing disability insurance, ask:

· How is disability defined? Some policies consider you disabled if you are unable to perform the duties of any job. Better plans pay benefits if you are unable to do the usual duties of your own occupation.

· When do benefits begin? Most plans have a waiting period after an illness before payments begin.
· How long do benefits last? After the waiting period, payments are usually available till you reach age 65, though shorter or longer terms are also available.

· What dollar amount is promised? Can benefits be reduced by Social Security disability and workers' compensation payments? Are the benefits adjusted for inflation? Will the policy provider continue making contributions to your pension plan so you have retirement benefits when the disability coverage ends?

What are the types of disability insurance?
There are two types of disability policies: Short-Term Disability (STD) and Long-Term Disability (LTD):

1. Short-Term Disability policies (STD) have a waiting period of 0 to 14 days with a maximum benefit period of no longer than two years.

2. Long-Term Disability policies (LTD) have a waiting period of several weeks to several months with a maximum benefit period ranging from a few years to the rest of your life.Disability policies have two different protection features that are important to understand.

1. Non-cancelable means the policy cannot be canceled by the insurance company, except for nonpayment of premiums. This gives you the right to renew the policy every year without an increase in the premium or a reduction in benefits.

2. Guaranteed renewable gives you the right to renew the policy with the same benefits and not have the policy canceled by the company. However, your insurer has the right to increase your premiums as long as it does so for all other policyholders in the same rating class as you.
In addition to the traditional disability policies, there are several options you should consider when purchasing a policy:

Life Insurance Tips

Why should I buy life insurance?
Many financial experts consider life insurance to be an important part of sound financial planning. Life insurance ca be beneficial in the following situations:

1. Replace income for dependents
If people depend on your income, life insurance can replace that income for them if you die. The most common situation is parents with young children. It can also apply to couples; newly married or seniors, in which the survivor would suffer financially burden by the loss of income with the death of a partner. Insurance to replace your income can be useful.

2. Pay final expenses
Life insurance can pay your funeral costs, debt, medical expenses not covered by health insurance, probate and other estate costs.

3. Create an inheritance for your heirs
You can create an inheritance by buying a life insurance policy and naming them as beneficiaries.

4. Pay federal “death” taxes and state “death” taxes
Life insurance benefits can pay estate taxes so that your heirs will not have to liquidate other assets or take a smaller inheritance. Changes in the federal “death” tax rules between now and January 1, 2011 will likely lessen the impact of this tax on some people, but some states are offsetting those federal decreases with increases in their state-level “death” taxes.

5. Create a source of savings
Some types of life insurance create a cash value that, if not paid out as a death benefit, can be borrowed or withdrawn on the owner’s request. Since most people make paying their life insurance policy premiums a high priority, buying a cash-value type policy can create a kind of “forced” savings plan. Furthermore, the interest credited is tax deferred (and tax exempt if the money is paid as a death claim).

How much life insurance do I need?
If you have no dependents and have enough money to pay your final expenses, you don’t need any life insurance; however, if you want to create an inheritance or make a charitable contribution, you should buy enough life insurance to achieve those goals.

If you have dependent children, you should buy enough life insurance to be able to combine with other sources of income, if applicable, that would equal the income you provided for your family.

Its important to name beneficiaries.
If you don’t name a beneficiary, the death benefit will be paid to your estate. Before your surviving heirs can receive any benefits it will need to go through the courts. That can take some time if there are complications. While your loved ones are waiting for the benefits to be paid, expenses are accumulating.

There are two types of beneficiaries “primary” and “contingent” beneficiaries. You should identify them as clearly as possible. Include their social security numbers and the relationship to the insured. This will make it easier for the life insurance company to find them, and it will reduce the possibility of disputes regarding the death benefits. If more than one beneficiary you should designate the amount of benefit for each.

In the event that a beneficiary can’t be found specify how the benefits are to be handled.

GLOSSARY
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

A
Accidental death and dismemberment (AD&D) rider - A supplement that can be added to many life insurance policies that provides an additional cash benefit to the insured’s beneficiaries if an accident causes either the death of the insured or causes the insured to lose any two limbs or the sight in both eyes.

Annual out-of-pocket maximum - A dollar amount set by the plan which puts a cap on the amount of money the insured must pay out pocket for covered expenses through the course of a calendar year.

B
Beneficiary - A person or party that the owner of a life insurance policy names to receive the policy benefit in the event of the insured's death.

Brand-name (medications) - Prescription medications that are manufactured by the initial developer of the medication.

C
Calendar-year deductible -The amount of health or dental care expenses that the insured must pay for covered eligible expenses before insurance payments.

Certificate of insurance – A document that describes the type and length of coverage provided by a group insurance policy that is given to each insured by the group policyholder.

Claim - A request for payment under the terms of an insurance policy; claims must be filed with in 60 days of the date of service.

COBRA (Consolidated Omnibus Budget Reconciliation Act) - COBRA requires organizations with qualified health plans that have twenty or more employees to offer the continuation of group health benefits (Medical, Dental, Vision, and Medical Reimbursement Account) to employees (and covered dependents) upon experiencing a "Qualifying Event." (examples of “qualifying events” - Termination of Employment , Reduction of Work Hours, Employee's Death, Employee's Divorce (or legal separation in some states), Medicare Entitlement, Change in "Dependent" Status)

Co-insurance - A specified percentage of covered expenses an insured is required to pay for all covered medical treatment remaining after the policy's deductible has been met. (ex: 80/20 plan 80% is paid by the carrier and 20% is paid by the insured)

Comprehensive major medical policy - A health insurance policy that covers both major medical expenses (i.e., hospitalization and surgeries) and basic medical expense coverages.

Co-pay - (1) A payment that many insurance plans require an insured to pay for certain medical services such as a physician's office visit or an amount that the insured must pay toward the cost of each prescription under a prescription drug plan. For example, you may pay $20 for an office visit or $10 to fill a prescription and the health plan covers the balance of the charges.

D
Deductible - A specified amount of money to cover medical expenses that an insured must incur before the insurer will make any benefit payments. (ex: A Hospital stay; A $500 deducible must be paid to the hospital by the insured, then co-insurance applies then the insurance carrier will pay their portion of the cost.)

Dependent - A person for whom the insured has some legal obligation or responsibilities. For most plans, it is the insured's spouse and/or children. Some plans also allow non-traditional spousal relationships (significant other, life-partner, etc.) to be considered a dependent with some additional certifying paperwork.

Domestic partner - Domestic partners are commonly defined as "two adults who share an emotional, physical and financial relationship similar to that of a married couple but who either choose not to marry or cannot legally marry. They share a mutual obligation of support for the basic necessities of life." Additionally, some carriers may require that domestic partners own property together to qualify.

E
Effective date - The specified date of when the insurance policy is to begin.

Emergency care - Most plans cover emergency care in a hospital emergency room if it is an extremely urgent medical emergency (life or limb threatening; the symptoms must be sudden, severe and require immediate medical attention), even if the hospital you are taken to is not in the plan's network. It is possible, however, that after your condition has been stabilized, you would be transferred to a participating plan hospital.

Employee contribution - The amount of premium the employer requires the employee to pay for his or her health insurance.

Eligibility period - The time during which a new group member may first enroll for group insurance coverage. Usually within 30 days of effective date.

Exclusions and limitations - Conditions, situations and services not covered by the health plan.

F
Fee schedule payment structure - A fee structure used by insurers under which the insurance company places caps or limits on the dollar amounts that it will reimburse providers for covered medical procedures and services, both in and out-of-network if applicable.

Formulary drugs - A formulary drug is one that has been thoroughly reviewed by a team of expert pharmacists and physicians; these drugs have been identified as safe, effective and beneficial to members for treating medical conditions. When deciding between drugs which are equally safe and effective, the formulary team also considers the relative costs of medications.

Fully insured plan - A group insurance plan for which an insurance company bears the responsibility of making all claim payments.

G
Generic (medications) – A generic drug is a copy of a brand-name drug. The Food and Drug Administration requires generic drug manufacturers to make all generic drugs with the same active ingredients, dosage, safety, strength, quality, and performance as the original medication. When a new drug is put on the market, the pharmaceutical company patents it under a brand name. The company has the exclusive right to sell the drug under this name (usually 20 years), but once its patent expires, other pharmaceutical companies can sell the same drug under its generic name. Generic drugs are typically cheaper than brand-name drugs.

group term life - A life-insurance plan that provides employees with additional coverage at economical group rates.

H
Health care provider -A doctor, hospital, laboratory, nurse or anyone else who delivers medical or health-related care.

Health insurance - A type of insurance that provides financial protection against the risk of excessive loss resulting from the insured person's sickness, accidental injury or disability.

Health Insurance Portability and Accountability Act of 1996 (HIPAA) - Under this federal law (known as HIPAA), group health plans cannot deny coverage based on an individual's health status. This law also gives employees who change or lose their jobs better access to health coverage, guarantees renew-ability and availability to certain employees and limits exclusions for pre-existing conditions. For example, under this law, group health plans must credit any employee the amount of time that they spent on any health plan prior to the new plan, which is known as "prior credible coverage." A pre-existing condition will be covered without a waiting period when an employee joins a new group plan if the employee has been insured for the previous 12 months with credible health insurance, with no lapse in coverage of 63 days or more. This means that if an employee has been insured for 12 months or more, the employee will be able to go from one job to another and his or her pre-existing coverage will remain intact -- without additional waiting periods. However, if an employee has a pre-existing condition and was not covered previously for 12 months before joining a new plan, the longest the employee will have to wait for their pre-existing coverage to be covered is 12 months.

HMO (health maintenance organization) - A health care system that provides comprehensive health care for subscribing members in a particular geographical area using managed care techniques. HMOs require that you only utilize physicians within their network.

HSA (health savings account) -
An HSA is a high deductible medical plan that includes a tax deferred savings account. The money from the savings account can be used to help meet the deductible or help pay early hospitalization/medical expenses

I
Indemnity plan - A health insurance plan that allows the insured to use any medical provider that he or she chooses. This plan has no networks to utilize. There are no co-pays or yearly max out of pockets with indemnity plans. These plans potential out of pocket for the insured can be costly.

In-network – The insured using a doctor or facility that is contracted to a network.

Insured - The person who is covered under an insurance policy.

L
Lifetime maximum - The maximum amount of money a plan will pay towards healthcare services through-out the insured's lifetime.

M
Major medical insurance plan - A type of traditional medical expense coverage that provides substantial benefits for hospital surgical expenses and physicians' fees.

Managed care - A method of integrating the financing and delivery of health care within a system that seeks to manage the cost, accessibility and quality of care. HMO, POS, and PPO plans are all managed care plans.

Member - The person who is covered under an insurance policy.

MSA – benefits - For the self-employed, Medical Savings Accounts (MSA) allow you to build up a tax-free savings account to pay for routine medical expenses. You build the account with tax-free dollars, and they remain tax-free while your MSA is active. Your MSA is used in conjunction with a high-deductible insurance policy. With the high-deductible insurance plan, the cost of an MSA can be kept competitively low. Tax-free dollars and an affordable price save you money.

N
Network - A group of doctors, hospitals and other health-care providers contracted with a health plan to provide care at discounted rates.

Non-formulary drugs - Non-formulary drugs are those that have not yet been reviewed or have been denied formulary status, typically because they offer no extra benefit over the drugs already on a plan's formulary list.

O
Out-of-network - Health care services provided by a doctor or facility that is not contracted with the health plans network.

Out-of-pocket expense - Any medical care costs not covered by insurance, which must be paid by the insured.

Out-of-pocket max – The total per year of medial expenses that an insured pays forwards the health plan’s co-insurance. (ex; Health plan’s coinsurance for the insured is 20% with a max out of pocket of $3000 plus deducible).

P
Point-of-service plan (POS) - An HMO plan that also incorporates an indemnity plan option (this will be out of network care) allowing members to obtain medical care from providers outside of the HMO network at a reduced benefit and at greater out-of-pocket expense. You can decide whether to go to a network provider for lower out of pocket costs, or go to an out-of-network provider and higher out of pocket costs.

Policy - A written document that contains the terms of the contractual agreement between an insurance company and the owner of the policy.

Policy year - The period of time that the policy is to remain in force; usually 12 full months.

Policy owner - The person or business that owns an insurance policy.

PPO (preferred provider organization) - An organization where providers are under contract to an insurance company or health plan to provide care at a discounted or negotiated rate. Typically, you can see any doctor in the PPO network without requiring special approval, and you usually do not need to choose a primary care physician. Most PPOs will also allow you to seek care outside of the PPO network; however, the benefits are usually reduced and the insured has a greater out-of-pocket expense.

Pre-existing condition - For individual health insurance policies, an injury or a sickness that occurred or manifested itself before the policy was issued. For group health insurance policies, a condition for which an individual was diagnosed or received medical care prior to the effective date of his coverage.

Pre-existing conditions provision - A health insurance policy provision stating that benefits will not be paid for any illness and/or condition that existed prior to one becoming an insured under the particular health plan in question, until the insured has been covered under the policy for a specified period.

Premium - A specified amount of money that the insurer receives in exchange for its promise to provide health insurance to an individual or a group.

Primary care physician (PCP) - A doctor who serves as the insured's personal physician to direct the course of your treatment and/or refer you to other doctors and/or specialists in the network.

Probationary period - The length of time that a new group member must wait before becoming eligible to enroll in a group’s insurance plan.

R
Renewal date - The specified date of when the health insurance coverage will renew for another period, typically a year.

S
Self-insured plan
A group insurance plan under which the employer takes complete responsibility for all claim payments and related expenses rather than purchasing coverage from an insurance company.

Short-term disability - This type of coverage pays a percentage of your salary if you become temporarily disabled, meaning that you are not able to work for a short period of time due to sickness or injury (excluding on-the-job injuries, which are covered by workers compensation). The per-week amount is usually 50, 60 or 66 2/3 percent of your weekly salary, and lasts for a period of time specified by the plan.

Standard industrial classification (SIC Code) - The Standard Industrial Classification (SIC) system is a series of number codes that attempts to classify all business establishments by the types of products or services they make available. Establishments engaged in the same activity, whatever their size or type of ownership, are assigned the same SIC code. These definitions are important for standardization. Insurance companies use SIC codes to determine specific rates for various industries. HealthInsurance.com uses these codes to ensure that you receive the best possible rate for your occupation.

Stop-loss - A major medical policy provision under which the insurer will pay 100 percent of the insured's eligible medical expenses after the insured has incurred a specified amount of out-of-pocket expenses in deductible and coinsurance payments.

T
Term life insurance - A type of life insurance that provides a death benefit if the insured dies during a specific period.

U
Underwriting - The process of identifying and classifying the degree of risk represented by a proposed insured.

Urgent care - Urgent care is appropriate when a medical urgency arises which necessitates immediate care, but has not reached a life or limb threatening true emergency. Most managed care plans require you to seek urgent care at a participating urgent care facility or hospital.

Usual, customary and reasonable fee - The maximum dollar amount of a covered expense that is considered eligible for reimbursement under a medial or dental policy.