Read more about Health Insurance
Health insurance may be supplied by:
• Group health insurance plan
• Single employer (large company, school district, church or government agency) self-insured health plan
• Union welfare benefit plan
• Individual health insurance
Where you fall in that spectrum will affect how much you pay for health insurance. The Martin Insurance Agency, work with a number of different insurance companies, which allows us to find the right policy that addresses your health insurance needs.
There are a number of types of business and personal health insurance policies to consider:
Health Maintenance Organization (HMO)
The “Maintenance” in the name refers to a philosophy of working to maintain your health now to avoid more serious medical conditions in the future. You may join an HMO through an employer program, union, or as an individual.
The cost of the insurance may be lower than with other plans and may include a monthly premium, co-pay or co-insurance. Pre-existing conditions are not excluded, but you may be charged a higher co-pay for coverage. There are no deductibles. You must see health care professionals, have tests done by labs, go to clinics and hospitals, and receive authorized prescriptions from within the specific HMO network. Some HMO’s will provide some form of coverage outside of the service area in the event of an emergency, but not all. Visits outside the network are generally not covered.
You will be required to pick a primary care physician who is responsible for coordinating care within the network and who is your first point of contact for any medical situation. It is important to familiarize yourself with your HMO’s guidelines for obtaining medical assistance. Services provided by the network are explained in the “evidence of coverage” as required by the Managed Care Reform and Patient Rights Act, 215 ILCS 134.
Preferred Provider Organization (PPO)
Preferred Provider Organizations often offer a wider network of health care providers than HMO’s and you can chose to see any provider within the network without the permission of a primary care physician. Care from providers within the network is covered to a predetermined percentage and out-of-network treatment may also be covered at a lesser percentage. Premiums consist of a monthly payment and possibly a co-pay or deductible. Prescriptions may or may not be covered.
Individual Major Medical Insurance
Short-term Health Insurance
This heath insurance will cover you only for the specified amount of time. There are numerous restrictions, usually including pre-existing conditions. However, this type of insurance can be very useful. For example, if your HMO does not provide coverage when you are out of the country, you could purchase short-term health insurance for your vacation.
Individual Major Medical
This type of policy provides coverage for specific health care situations for individuals and their family. Coverage is often less than that provided by a group policy and more expensive. Application for coverage generally requires completing medical histories. Everything requested on the application should be filled out completely and honestly so as not to risk a denial of benefits. Medical evaluations may be required and you may be denied coverage or charged a higher premium due to pre-existing conditions. Waiting periods, limitations and/or exclusions based on a pre-existing condition or other factors may come into play. Comparison shopping is suggested as policies vary from company to company.
Dental and Optical
Policies covering dental and optical services vary tremendously. Talk over your family or company situation with a Martin Insurance agent to determine policies that will best fit your needs.
Hospital Confinement Insurance
This insurance helps to cover family expenses associated with a hospital stay. These may include not only deductibles and co-insurance payments, but also ancillary hospital fees not covered by insurance, lodging, transportation, meals, childcare expenses and certain incidentals.
Money Saving Health Care Accounts
Flexible Spending Account
Employers offering cafeteria-style benefits can set up Flexible Spending Accounts for their employees that allow the employees to set aside pre-tax funds to pay for qualified expenses. Employers benefit through reduced payroll taxes. The account can be used to pay for medical expenses not covered by insurance plans such as deductibles, co-payments, co-insurance, specific over the counter drugs for which a doctor has written a prescription and some supplies. Employers may currently set a limit as to how much income can be deposited. Effective 2012, there will be a federally mandated limit of $2,500. If you are covered by a High Deductible Health Plan and Heath Saving Account, you cannot have a Flexible Spending Account but may have a Limited Expense (LEX) flexible spending account to cover dental and vision expenses.
Funds not used within the coverage period (usually the beginning to the end of the plan year or upon termination) are forfeited, so it becomes extremely important to accurately access your needs.
Health Reimbursement Accounts (HRA)
These accounts can be used with High Deductible Health or standard health plans, but do not require that an employee be covered by a health insurance plan in order to participate. The expenses that qualify under the plan are designated by the employer and have maximums. The employer funds the accounts, therefore, the money is not part of the employees income but is an expense deductible by the employer. Unlike an FSA, all or part of the funds remaining at the end of a plan year can be rolled over to the next year at the employer’s discretion.
This program is not available to self-employed individuals. However, if a spouse is legitimately hired, legitimately works for the business and is issued a W-2, an HRA account can then be set up for the spouse. This saves both the family (offsetting medical expenses) and the company (through legitimately deductible expenses).
If you are 65 or older, have a Medicare insurable disability, Lou Gehrig’s disease or kidney disease you may be eligible for the federally funded Medicare program. It will cover a large portion of your medical expenses. Many of the deductibles, co-insurance, co-payments, and some services not covered by Medicare can be covered by a Medicare supplement insurance policy. If you belong to a Medicare Advantage plan, Medicaid or a Qualified Medicare Beneficiary Program, you may not need supplemental insurance.
It is suggested that you discuss your options with the Martin Insurance Agency at least six months before you will reach age 65, will cease to be covered by insurance from an employer (if you plan to work past age 65), or as soon as you determine you may be eligible for Medicare. This will allow you to meet the time limits specified by Medicare and still allow you to determine which supplemental insurance policy best fits your situation, without having a gap in coverage.
There are 12 government standardized Medicare supplement insurance plans (named A-L). You may also need to purchase a Prescription Drug Plan (Part D).
Here again is a situation where having an Independent Insurance Agent such as the Martin Insurance Agency, can be useful in helping you understand the options offered by each type of plan.
Policy coverage is subject to the terms, provisions, exclusions, conditions and endorsements as stated in the policy.
If you have any questions, please call the Martin Insurance Agency at 847.526.5755