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Health Insurance FAQs:
Health Insurance Answers:1.What is considered a preexisting condition? A preexisting condition is any health condition you have or have had prior to applying for a policy. For example, if you have had kidney stones at any time during your life, then kidney stones would be considered a preexisting condition. Some insurance companies want to know about your preexisting condition going back as far as your date of birth, but most insurance companies only look back ten years. 2.
Will a preexisting condition prevent me from obtaining health
insurance? Sometimes
yes, sometimes no. It will depend upon the condition you have or had, its severity,
the cost of medications, and whether the insurance company thinks it will lose
money by giving you a policy. Some preexisting conditions will not exclude you
from getting a policy; instead, the insurance company may issue a policy to you,
but they might try to offer you the policy with a "rider" which is a
clause in your policy that says the insurance company will cover you, but NOT
give you coverage for your preexisting condition. Some companies might offer you
their policy with a rider that the company says you may ask them to remove after
a certain length of time, such as two years, and other companies may make the
rider permanent. 3. What are some common preexisting conditions that prevent people from obtaining health insurance? Alcoholism and drug abuse are usually two conditions that most insurance companies will turn you down for. Others include heart attack or other heart problems within the past five years or so, most companies will not take you if you are diabetic. Many companies will not accept you if you've had certain types of cancer EVER in your life, while other insurance companies won't care if the cancer was more than 20 years in the past. It's almost impossible to get health insurance if you are currently obese or pregnant. Having AIDS is always an automatic decline, as is a stroke in your recent past. Most companies won't care if you have controlled hypertension (high blood pressure) or controlled high cholesterol. But if you have BOTH at the same time, there are very few companies that will offer a policy to you. 4. What kind of options are there for people that cannot obtain health insurance due to preexisting conditions? There are some high quality guaranteed issue health insurance plans available today that will cover most preexisting conditions after you've been on the policy a period of time, usually one year. These policies have some conditions you'd have to meet in order to get a policy, such as requiring that you are gainfully employed or a member of a certain association. 5. I'm currently pregnant and I don't have any health insurance. What should I do? There are no health insurance companies that will give you a policy if you are pregnant. If you do not have any health insurance and you are pregnant, contact your local welfare office if your income is low enough to allow you to get on state assistance. If your income is too high to qualify, call all of the hospitals in your area and ask what types of pre-payment plans they offer. You may find that for the same amount of money you'd pay monthly for a health insurance plan that included maternity benefits, you can pay a provider up front on a monthly basis and come out almost even. You'll still need to contend with the doctor's (obstetrician) bills, however. Try to contact local obstetricians and explain your situation. You may find a sympathetic ear who will allow you to make payments to him/her. 6. How long do I have to wait before I can get pregnant? That depends upon what your insurance policy says. Some, but very few, companies will let you apply for a policy as long as you are not pregnant when they issue you their policy. Then you can get pregnant as soon as you want. None of the insurance companies we represent work this way any longer. Most companies today make you wait at least one year after your policy goes into effect before they will pay for any maternity benefits, which means you may get pregnant after you've been on the policy for three months. Yet other companies say you must have their policy for 12 months before you can get pregnant (or at least expect them to pay your maternity bills), which would mean your pregnancy would not be a covered expense until you've been on the policy for 21 months. 7. I'm planning to change jobs, but I'm also pregnant. Should I be concerned about qualifying for health insurance coverage? Federal law provides some degree of protection for pregnant women who change jobs. Under the Health Insurance Portability and Accountability Act (HIPAA), pregnancy cannot be considered a preexisting condition for a woman who is changing jobs if she was previously covered by a group health insurance plan. So if you had insurance at your old job, you can't be denied health insurance coverage at your new job simply because you're pregnant. However, this doesn't necessarily mean your worries are over. Although most health insurance policies provide coverage for maternity care and pregnancy, it's important to check the specifics of your new employer's health insurance plan to make sure you are covered. HIPPA doesn't protect your right to maternity and pregnancy coverage if your employer doesn't offer it. If you didn't have health insurance before you started your new job, or if you were covered by an individual health insurance policy, you do not qualify for the protection offered under HIPAA. In this case, you might be subject to a preexisting condition waiting period under your new employer's health insurance policy. Many companies also require you to be employed for 30 days or more before you become eligible for coverage. That may not be a problem if you are early on in your pregnancy and have the resources to pay for one or two prenatal visits out of your own pocket. If you are nearing the end of your term, however, a few weeks without health insurance could be financially disastrous. You may be eligible for coverage under COBRA (Consolidated Omnibus Budget Reconciliation Act) through your former employer. However, this will generally require you to pay the full premium. Keep in mind that some employers don't provide health insurance coverage at all. And being caught without group health insurance can be a serious problem for a pregnant woman. Individual coverage may be an option, but you may find it difficult to find an insurer who will cover you if you're already pregnant. In addition, the premiums on such a policy could be extremely high. As you can see, it's important to do some careful planning before making a career move when you're pregnant. To protect your health and the health of your baby, make sure you completely understand the employer's health insurance plan and eligibility requirements before accepting a new job. 8. What is a guaranteed issue health insurance plan?Guaranteed Issue Health Insurance is just what it says -- if you apply for the policy, you will receive it, regardless of any preexisting health conditions. But most of these policies are not considered major medical policies. They are considered mini medical policies. They will pay some of your bills, but not all. If you got very sick and your medical bills were in the hundreds of thousands of dollars, you'd probably have to pay a large amount of those bills. Most higher quality mini-medical plans (guaranteed issue TRUE health insurance plans, as opposed to simple medical discount plans, which are not insurance policies) will pay you around $1,000 per day when you are hospitalized (and more if you end up in an intensive care unit), for up to 30 to 100 days per year. They also will pay a predetermined amount for a surgeon, but many times the amount paid to the surgeon may not be enough to pay his or her bill in full. Scrupulous insurance brokers will usually only offer these types of policies to those people who have severe preexisting health conditions that would make it impossible to get a major medical health insurance plan. If you've had a heart attack or stroke or cancer in the recent past, you'll find it literally impossible to get a major medical policy, such as a policy from a company like Blue Cross. If you find yourself in this position, a mini medical plan is better than nothing, and some of these plans are high quality plans and, if used "according to the rules" can pay a large percentage of your medical bills. 9. What is a deductible and how does it work? Typically, a deductible is the amount of money you must pay each year before your health insurance plan starts to pay for covered medical expenses. For example, with a $100,000 heart surgery bill, you would be responsible for paying the first $1,000. After this $1,000 deductible is met, the insurance company will pay a percentage of the bill in what is called the coinsurance. Coinsurance is a cost-sharing requirement where you are responsible for paying a certain percentage and the insurance company will pay the remaining percentage of the covered medical expenses after your deductible is met. For a health insurance plan with 20% coinsurance, once the deductible is met, the insurance company will pay 80% of the covered expenses while you pay the remaining 20% until your out-of-pocket limit is reached for the year. Typically, the out-of-pocket limit is the maximum amount you will pay out of your own pocket for covered medical expenses in a given year. For a plan with a $2,000 out-of-pocket limit, you will pay a $1,000 deductible and $1,000 coinsurance while the insurance company covers the remaining $98,000 of the heart surgery bill. Even if you are hospitalized again in the same year, the insurance company will pay 100% of your covered expenses within the limit of the lifetime maximum. A co-payment or co-pay is a specific flat fee you pay for each medical service, such as $30 for an office visit, after which the insurance company often pays the remainder of the covered medical charges. Let's say you are not feeling well and went to see your doctor who charges $200 for the office visit. If your insurance plan has an office visit co-payment of $30, then you will only be responsible for the $30 and the insurance company will cover the remaining $170. 12. What is "Out-of-Pocket-Maximum"? This is the amount of money one would pay out of their own pocket towards their medical expenses in any given year. An out of pocket expense can refer to how much the co-payment, coinsurance, or deductible is. Also, when the term annual out-of-pocket maximum is used, that is referring to how much the insured would have to pay for the whole year out of their pocket, excluding premiums. Usually, your maximum out-of-pocket is never more than a couple of thousand dollars over and above your chosen deductible. 13. What's the difference between a Primary Care Physician (PCP) and a specialist? A Primary Care Physician, or PCP, is the doctor you would go to on a regular basis, such as when you're simply not feeling well, or have an ear ache or the flu. A specialist is a doctor that your PCP might refer you to if the problem you have requires a doctor with more experience in a certain area. For example, if you contacted your PCP complaining about chest pains, your PCP would most probably refer you to a heart doctor (a cardiologist) who would have more advanced equipment and training to help you. 14. What is the main difference between an HMO and a PPO? Most HMOs require you to select a specific doctor as your primary care physician, or PCP. This doctor is supposed to be your first "port-of-call" for most any medical condition, although exceptions are typically made for emergencies. As such, he or she will end up providing most of your medical care. Your choice of specialists and hospitals is usually limited to those already under contract with the HMO, and your primary care physician is the one who decides whether or not a referral to a specialist is actually necessary. One major benefit of an HMO is that maternity is a covered expense. PPOs combine some of the characteristics of HMOs with the flexibility of traditional fee-for-service plans. PPOs offer a specific set of doctors and hospitals that the member can choose from to get discounted rates. These are called "preferred" or "in-network" providers. PPO members are free to see any in-network provider at any time. Members can also see doctors who are not in the network, but the co-insurance payment for those doctors will be higher. Maternity benefits are not usually included on PPO plans. 15. What are the differences in the levels of care and coverage with long-term care insurance? The phrase "long-term care" refers to a broad range of medical and personal services. Long-term care goes beyond standard hospitalization and nursing care, and includes all the assistance you could need if you are unable to care for yourself for an extended period of time. For purposes of long-term care insurance (LTCI), there are three levels of long-term care. It is important to understand the distinctions between these levels in order to ensure that the policy you buy includes the coverage you want.
* Skilled care *
Intermediate care *
Custodial care Most LTCI policies cover skilled, intermediate, and custodial care in licensed nursing homes. However, long-term care can be provided in a number of other places, including adult day care centers, assisted living facilities, hospices, and even your own home. LTCI policies may limit the additional facilities in which you can choose to receive care. Benefit
choices: You will probably also need to choose a benefit period, which is the maximum length of time that benefits will be provided (e.g., one year, three years, five years, etc.). After the applicable time limit has been reached, no further benefits are paid. Lifetime benefits are also available, but as you would probably expect, LTCI premiums are higher for policies with longer benefit periods. Some policies have different benefit periods for different types of care. 16. If a company goes out of business, are the employees eligible for COBRA even though there is no longer a health insurance policy for the company? In most cases, no. Under the Consolidated Omnibus Budget and Reconciliation Act of 1985 (COBRA), workers who lose their jobs may have the right to continue group health care coverage under their employers' plans. Unfortunately, however, if the company goes out of business and no longer has a group health insurance policy in force, then COBRA coverage is no longer available. One possible exception: union employees who are covered by a collective bargaining agreement may be entitled to COBRA coverage if the agreement provides for a medical plan. The good news is that employees who are not eligible for group coverage under COBRA may still be able to obtain group health insurance elsewhere. For instance, they may find a new job with an employer who provides health insurance or may be eligible for employer-sponsored coverage through a family member's employer-sponsored plan. And, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the health coverage they had through their former employer may "count" towards reducing or eliminating any preexisting condition exclusion that might apply when they seek group health insurance with another employer. In addition, there are other sources of health insurance at opposite ends of the price spectrum: low-cost or no-cost health insurance coverage through a public program sponsored by their state's unemployment office or more expensive individual health insurance that can be purchased through insurance companies. |
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