friday afternoon

Vail

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Preventative Care Benefits under Reform

Under the Affordable Care Act, you and your family may be eligible for some important preventive services—which can help you avoid illness and improve your health—at no additional cost to you.

What This Means for You

If your plan is subject to these new requirements, you would not have to pay a copayment, co-insuranceor deductible to receive preventive health services, such as recommended screenings, vaccinations and counseling.

For example, depending on your age, you may have free access to preventive services such as:

• Blood pressure, diabetes, and cholesterol tests
• Many cancer screenings, including mammograms and colonoscopies
• Counseling on such topics as quitting smoking, losing weight, eating healthfully, treating depression and reducing alcohol use
• Routine vaccinations against diseases such as measles, polio or meningitis
• Flu and pneumonia shots
• Counseling, screening, and vaccines to ensure healthy pregnancies
• Regular well-baby and well-child visits, from birth to age 21

Some Important Details

• This preventive services provision applies to people enrolled in job-related health plans or individual health insurance policies created after March 23, 2010. If you are in such a health plan, this provision will affect you as soon as your plan begins its first new “plan year” or “policy year” on or after September 23, 2010.
• If your plan is “grandfathered,” these benefits may not be available to you.
• If your health plan uses a network of providers, be aware that health plans are only required to provide these preventive services through an in-network provider. Your health plan may allow you to receive these services from an out-of-network provider, but may charge you a fee.
• Your doctor may provide a preventive service, such as a cholesterol screening test, as part of an office visit. Be aware that your plan can require you to pay some costs of the office visit, if the preventive service is not the primary purpose of the visit, or if your doctor bills you for the preventive services separately from the office visit.
• If you have questions about whether these new provisions apply to your plan, contact your insurer or plan administrator.  If you still have questions, contact your State insurance department.
• To know which covered preventive services are right for you—based on your age, gender, and health status—ask your health care provider. 

Please call the shoppe with any questions....

Thanks,

Jordan

What Does Having a "Grandfathered" plan mean under reform?

The Affordable Care Act exempts most plans that existed on March 23, 2010--the day the law was enacted--from some of the law’s consumer protections. This will preserve consumers’ rights to keep the coverage they already had before health reform.

What This Means for You

If you have health coverage from a plan that existed on March 23, 2010--and that has covered at least one person continuously from that day forward--your plan may be considered a “grandfathered” plan.

This is true whether you are covered by an individual health insurance policy that you had on that date, or you are covered by a job-based health plan that your employer first established before March 23, 2010. This is true even if you enrolled in that job-based plan sometime later.

A grandfathered health plan isn’t required to comply with some of the consumer protections of the Affordable Care Act that apply to other health plans that are not grandfathered.

Here’s a look at which consumer protections do and don’t apply to grandfathered plans.

Consumer Protections in the Affordable Care Act that DO Apply to Grandfathered Plans

Many of the Act’s consumer protections that took effect on September 23, 2010 apply to all plans, whether or not the plans are grandfathered.

Please note that these consumer protections will be added to your plan when it begins a new plan year orpolicy year on or after September 23, 2010.

All health plans:

• Are prohibited from applying lifetime dollar limits to key health benefits.
• Are not permitted to cancel your insurance coverage solely because of an honest mistake that you or your employer made on your insurance application.
• Must extend dependent coverage to an enrollee’s adult children until they turn 26 years old (with one temporary exception: Click here for more details).

Consumer Protections in the Affordable Care Act that DO NOT Apply to Grandfathered Plans

Unlike other health plans, job-based plans and individual insurance policies that are grandfathered arenot required to:

• Provide certain recommended preventive services at no additional charge to you.
• Offer new protections for consumers who are appealing claims and coverage denials.
• Protect your choice of health care providers and your access to emergency care.

Consumer Protections in the Affordable Care Act that DO NOT Apply to Grandfathered INDIVIDUAL Plans

Grandfathered individual health insurance policies are not required to adopt the provisions of the law that:

• Phase out annual dollar limits on key benefits.
• Eliminate pre-existing condition exclusions for children under 19 years old.

Some Important Details

Grandfathered plans can lose their grandfathered status if they make certain significant changes that reduce benefits or increase costs to consumers. (Read more about changes that will cause a health plan to lose grandfathered status).

Although grandfathered plans can make only limited changes to the percent of the premium the employer contributes, grandfathered plans may still increase their total premium amount without losing grandfathered status.

If your plan loses its grandfathered status, all of the Affordable Care Act consumer protections would apply to you when your plan begins a new plan year or policy year.

To find out if your health plan is grandfathered:

• Check your plan’s materials. Beginning with the first plan or policy year starting on or after September 23, 2010, health plans must disclose their grandfathered status in any plan materials describing the plan’s benefits that are distributed to beneficiaries or primary subscribers. These materials must also contain contact information for questions and complaints.
• Check with your employer and/or your health plan’s benefits administrator. If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to a grandfathered group plan after March 23, 2010.

For additional questions please contact the shoppe.

Thanks,

Jordan

Insurance Protection for Children

Under the Affordable Care Act, health plans cannot limit or deny benefits or deny coverage for a child younger than age 19 simply because the child has a “pre-existing condition”—that is, a health problem that developed before the child applied to join the plan.

What This Means for You

Until now, plans could refuse to accept anyone because of a pre-existing health condition, or they could limit benefits for that condition. Now, under the new law, health plans that cover children can no longer exclude, limit or deny coverage to your child under age 19 solely based on a health problem or disability that your child developed before you applied for coverage. This new rule applies to all job-related health plans as well as individual health insurance policies issued after March 23, 2010. The rule will affect your plan as soon as it begins a plan year or policy year on or after September 23, 2010.

Some Important Details

• This rule applies whether or not your child’s health problem or disability was discovered or treated before you applied for coverage.
• The new rule doesn’t apply to “grandfathered” individual health insurance policies. A grandfathered individual health insurance policy is a policy that you bought for yourself or your family (and is not a job-related health plan) on or before March 23, 2010 (the date that the new law was passed).
• These protections will be extended to Americans of all ages starting in 2014.

Example

On October 1, 2010, Sally purchased a new individual health policy for herself and her 13-year-old child, Miranda, who has been treated for asthma in the past. The new health policy excludes coverage for treatment of pre-existing conditions for all enrollees. On November 1, 2010—one month after coverage began for Sally and Miranda—Miranda is hospitalized for an asthma attack. Her insurance company denies payment for the hospitalization, because under the policy Miranda’s asthma is considered a pre-existing condition.

Under the new law, the insurer can’t deny payment for the hospitalization based on Miranda’s pre-existing asthma condition. Miranda is under the age of 19; Sally’s policy is new and therefore subject to the pre-existing condition rules of the new health care law. Sally’s policy year began after September 23, 2010, when the law’s rules on pre-existing conditions began to take effect.

Please call the shoppe with questions.

Thanks,

Jordan

Appealing a decline in coverage

Your Benefit Appeal Rights Under the Affordable Care Act

If your health plan was created after March 23, 2010, the Affordable Care Act ensures your right to appeal, or to ask that your plan reconsider its decision to deny payment for a service or treatment. New rules, now in effect, govern how your plan itself must handle your initial appeal. If your plan upholds its decision after its internal review, the law permits you to appeal to an independent reviewer who does not work for your health plan.

What This Means for You

• When an insurance plan denies payment for a treatment or service, you can appeal to the plan to review its own decision. Your plan must explain how to appeal when it informs you of the denial.

• When you appeal, your plan must give you its decision within:
  • 72 hours for denials of urgent care.
  • 30 days for denials of non-urgent care you have not yet received.
  • 60 days for denials of service you have already received. 

• If the plan still denies your request, it must explain why and tell you how to appeal for an independent review of the decision. In some cases involving urgent care, you may be able to have the internal and external review take place at the same time.

• If you do not speak English, you may be entitled to receive all appeals-related information in your native language.

Some Important Details

• The appeals provision applies to all health plans created or purchased after March 23, 2010  and affects each plan as that plan starts a new “plan year” or “policy year” on or after September 23, 2010.
• How much the law will change your appeal rights depends on the State you live in and the type of plan you have.  
• Some employers’ plans may have more than one internal review before you’re allowed to seek an external review.
• If you have questions about whether the appeals provision applies to you, ask your health plan orState insurance regulator. Your State may also have a health care consumer assistance program that can help.

Please call the shoppe with any questions...

thanks,

Jordan

Which Carrier to Apply for Coverage With?

All carriers will have a benefit that stands out amongst others.

When looking for plans that are the most competitive in premium, one carrier will stand out in Cook County, Blue Cross and Blue Shield of Illinois (BCBSIL).  Hands down, when comparing quotes, BCBSIL will be the lower priced plan 90% of the time.

Does this mean that you should apply to BCBSIL?  Unfortunately not.

With BCBSIL, all pre-existing conditions will not be covered for the 12 months of coverage.  This means any condition that was consulted, diagnosed or treated within the 12 months prior to coverage, excluding birth control.  BCBSIL along with all carriers other than Aetna can exclude coverage on specific medical conditions.

So...if you are Asthmatic and take Generic or Brand Name medications, these would not be covered for the first year, making BCBSIL not the best option.

If the prospective insured is currently taking medications, Humana, and UnitedHealthCare (UHC) may be a better option.  These carriers do not have a pre-existing condition waiting period and will cover your Rx from day one.  However, depending on the cost of your Rx, quoted premium can increase to cover the cost of medication.

Aetna can be an option but will only waive the 12 month pre-ex waiting period if the prospective insured was covered continuously for 12 months with no longer than a 63 day gap in coverage.  Aetna will not place exclusions on a policy but can increase the quoted premium.  Aetna all does not cover Mental and Illness.

For more information on plans please contact the shoppe.

-Jordan

Do you know how a copay works for office visits?

Do you have an office visit copay?  If so...with new healthcare reform, this copay is only applicable for office visits other than preventative care which is covered at 100% by your insurance carrier.

A copy is only to cover the cost of consultation..any and all additional lab work or diagnostic testing falls under a deductible expense.

So, for primary care when you are an established patient, the true cost after insurance can be anywhere from $40-$60 to what you will be billed by the provider.  If you have a copay then this will pick up that cost and is owed at time of service.

By not having a copay you will be billed the allowed amount (negotiated/contracted rate) to which is applied towards the plan deductible, chipping away at your total exposure.

Choosing a plan without a copay can save an insured anywhere from $30-$40/month.  Therefore, when you are billed the premium savings will make up the difference by not having a copay and you receive the benefit of having the expense go against the deductible, where copays do not.

Now, the only time a copay might be beneficial is when the insured is a "new patient" for a specialist or non-specialist.  When an insured is a new patient they will be billed a higher amount than normal.  This can be anywhere from $150 for primary to $300 for a specialist.  Once insurance is presented the cost will drop anywhere from 30-70%.

Once the insured is an "established patient" the cost will be dropped as noted above.  For specialists, an insured can expect to pay anywhere from $50-$80 after insurance.

Most plans now have copays of $20-$35 for primary with $35-$60 for specialists.

For more information please call the shoppe.

-Jordan

New Preventative Care Benefits

For those who have had a health insurance policy issued later than 3/23/2010, effective 1/1/2011 your preventative care benefits are covered at 100% by your insurance company with no annual maximums.

Please click the below link for a list of services that the department of Health and Humana Services (HHS) deem covered.
http://bit.ly/9twrh5

Now, as of late...clients of the shoppe have been receiving bills from their insurance company for their recent routine annual checkup.  Depending on doctors, these visits can cost $150-$260 after insurance.  This is the amount that your Explanation of Benefits (EOB) states you may owe the provider.

When reviewing these EOB's, physicians are coding their claims as medical visits with all lab work being billed as diagnostic.  This leads to the insured receiving a bill for covered expenses.

If this is happens, you must call your provider and ask for them to resubmit claims under the right coding and must include medical records for that day of service.

If you have not had your annual checkup...make sure to notify the providers office to code claims as preventative or routine.

Please feel free to contact the shoppe with any questions on this.

Thanks,

Jordan

Mental Health Benefits

Mental Health benefits are different amongst each carrier in the private market and are a cutback in benefits compared to employer provided coverage.

If you currently are covered through your employer, Mental Health benefits are covered the same as any other illness.  So...if your plan has a copay for office visits (out-patient medical services), than any therapy is covered under the copay...as long as your provider is "in-network"

In the private market Mental Health benefits are not covered the same as any other illness.  Below is a list of how each carrier the shoppe represents covers Mental Health benefits:

Aetna

Does not provide coverage

Blue Cross and Blue Shield of Illinois (BCBSIL)

12 month waiting period if considered a pre-existing condition.  All expenses are subject towards the plan deductible prior to being paid at 50% towards the plans out-of-pocket and after.

Celtic

12 month waiting period if considered a pre-existing condition.  All expenses are subject towards the plan deductible prior to being paid at the selected coinsurance level towards the plan out-of-pocket.

Humana

12 month waiting period, except for prescription drugs.  Separate plan deductible for Mental Health, then paid at 50% towards the plan out-of-pocket and after.

United HealthCare (UHC)

Mental Health benefit is additional premium with no waiting period.  All expenses are subject towards the deductible before being paid at selected coinsurance level towards the plan out-of-pocket.

Please call or email the shoppe with any questions.

Thanks,

Jordan

Office Visit Copay or Not???

Having trouble choosing a plan of coverage?
Do the plans that you can afford not have office visit copays?
Are they limited?

No matter which plan you choose the #1 benefit every member of each carrier receives is that they have access to the provider network.  When you seek service at a "in-network" provider you are subject to the negotiated rate of service, not retail..prior to the plan deductible being met.

The negotiated rate is applied to all covered expenditures.

All plans will cover preventative care services at 100% with no cost obligation to the insured.

So..back to having an office visit copay.

So, if your plan has a copay, then this is a fixed amount, on the negotiated rate, that you will pay for the cost of consultation when visiting a specialist or non-specialist.  The copay amount paid does not apply towards the plan .  Some carriers have 2 separate copay amounts, one for a specialist and one non (lower).

Clicking this office visit claim for a recent specialist visit of mine, will show the final cost I owe the provider after my insurance carrier, BCBSIL, processed the claim.  The retail cost was $170 in which I was only allowed to be billed $71.

If my plan had a copy I would have owed at time of service.  By not having a copay, I am billed this amount by the provider, and when paid, it goes against my deductible reducing my overall risk.

Keep in mind that this visit was for a specialist and I was an established patient.  If I had been a new patient, the retail cost would be close to $300.

Now, when choosing a plan you may notice that the copay amount is the difference in price between a plan without.  So..if you have do not visit the doctor frequently, the premium savings will be enough to cover the cost of your office visit consultation.

For any questions please contact the shoppe.

Thanks,

Jordan

HumanaOne Introduces New Plans Effective 1/22

HumanaOne will begin to offer new plans with more deductible options beginning 1/22/2011.

I have placed links to their new materials on the right side of my blog for your review.

These new plans will have more deductible offerings, plus condition specific exclusion riders.  What does that mean?  For applicants who apply to Blue Cross and Blue Shield of Illinois (BCBSIL) and receive an exclusion on a specific condition, Humana will come and offer a separate deductible for that condition.

Please contact the shoppe with any questions.

Thanks,

Jordan

Considering Dental Insurance?

As of  late many of the insurance carriers that I represent now offer a stand-alone dental plan, not only available with your current health insurance plan.

Before selecting this optional benefit, it is important to understand how dental insurance works.

1. Does your dentist accept the plans terms of service and is he considered to be a "In-Network" or "Out-of-Network" provider.  If your dentist is "In-Network" than the dental plan will provide greater benefits.
2. Preventative Services such as cleanings and X-Rays are covered 100%
3. All plans have a 6 month waiting period for Basic Services (cavities, fillings, extractions) and a 12 month waiting period for Major Services(root canal, crowns, dentures, restorative).  After waiting periods, member pays either 20% or 50% of allowable charges.
4. All costs that are paid out by the insurance carrier are applied towards the plans $1,000 or $1,500 annual benefit maximum

The only way around the waiting periods is acquiring a dental plan from Blue Cross and Blue Shield of Illinois (BCBSIL) that must be taken when applying for a plan of health insurance coverage.  BCBSIL only has a 12 month waiting period for crowns, dentures and restorative.

If your teeth are in great shape and you seek semi annual cleanings, you may want to weigh the cost of coverage to the actual cost you are to pay retail.

If you do not have a dentist, then it might be wise to acquire a plan to cover the cost of your initial "new patient" consultation and cleaning, especially if you plan on going twice a year.

If you just found out that extensive work is needed, your best bet would be BCBSIL since there are not any waiting periods for Basic Services and a few Major Services.  If not BCBSIL, none of the plans will be a benefit.

Fore more information please contact the shoppe.

-The Shoppe

Maternity Coverage in Illinois

Happy Holidays and Merry Christmas!

I hope that the readers of my postings, which are few, had a great holiday weekend :)

As of the past month there have been quite a few inquiries on obtaining maternity coverage in the private market.  Unfortunately, there is only one private health insurance carrier that offers an optional Maternity benefit, Blue Cross and Blue Shield of Illinois (BCBSIL).  This optional benefit must be elected at time of application or on the anniversary date of a current BCBSIL plan.

The benefit is payable after a 12 month waiting period with continual monthly premium payments.  All pre-natal care will be covered after the waiting period to then include delivery and post-natal care.  After the waiting period all covered care will be subject to your plans coverage.  Once post-natal care is completed you will then request to remove the Maternity benefit.

If a plan member with the maternity benefit delivers by Cesarean C- Section and removes the benefit, and is to add the benefit again at plan anniversary, there will be complications.

When applying for the benefit at anniversary, all members of the plan must go through medical underwriting, and until January 1st, 2014 (health care reform), BCBSIL can place condition specific exclusion riders.  For example, BCBSIL would offer the optional Maternity benefit but will place an exclusion on future C- Sections, not covering it at all.

Now...the final thing to mention is the Maternity Benefit that is available with the Illinois Comprehensive Health Insurance Plan (ICHIP).  ICHIP is the state high risk pool and the benefit is available with their Traditional coverage option.  To qualify for this coverage you must not be insurable in the private market or have a private policy that is more costly than the ICHIP.  The optional Maternity benefit has a 9 month waiting period.

For additional information on Maternity coverage please contact the shoppe.

Best,

The Shoppe

BCBSIL has updated their effective date guidelines

Effective 12/1/2010, Blue Cross and Blue Shield of Illinois (BCBSIL) has new effective date guidelines.

You can now request an effective date 2 weeks out from the date you submit your application.  If a decision has not been made within the 2 weeks, your effective date will be on approval, but can not be the 29th, 30th or 31st of the month.

Please contact the shoppe with any questions.

-The Shoppe

Recent Visit to the Emergency Room

Well...not so recent as I am late in keeping up with updating our BLOG.

Back in August I had cut my finger with a knife when I was packing up my apartment.  There was no to much pain but a whole lot of bleeding.  After 20 min of continuous bleeding I decide to visit the Emergency Room (ER) as it was during the middle of the night.

Living in the Gold Coast I chose to visit St. Joseph's which is Resurrection HealthCare.  I was treated right away and during my 45 minute stay I received gel foam to help coagulate the blood on the cut, which was wrapped up with a band-aid.  I was then visited by a physician who went over the gel foam and told me to keep it on for 24 hours and then let it heal naturally.

Two weeks following my visit I received a bill from Resurrection HealthCare for $1072.50 which was for Facility Emergency Services.  The next day I received another bill, this time for Physician Services which was for $196.  This brought my total bill to $1,268.50.

$1,268.50 is the retail cost and is the cost one would be responsible to pay if not covered by health insurance.

Being self-employed I have private health insurance coverage with Blue Cross and Blue Shield of Illinois (BCBSIL), in which I presented my insurance card at time of service.  The plan I have is HSA compatible with an annual $2,600 deductible then 100% coverage after. My plan design leaves me to pay up to the my deductible before BCBSIL is to pay a percentage or all.

Back to the bills....

Once I received all billing from Resurrection I then received two Explanation of Benefits (EOBs) from BCBSIL that went over my recent visit, costs and then showed the allowable amount I was to be billed for these services.  The "allowable amount" also known as the "negotiated/contracted rate" is the amount the provider (Resurrection) is allowed to bill me since they accept BCBSIL and are considered an "in-network" provider.

Another week went by and I then received updated billing from Resurrection requesting the reflected amount on my EOBs.  This final amount is what I owe to the provider and is applied towards my deductible.

The final costs were $521 for Facility Services and $56 for Physician Services, $577 total. This is how health insurance works! 

No matter what my plan benefits are compared to anyone else with BCBSIL this would be the plan members responsibility prior to their plan benefits.

Now....the final thing to discuss is how the plan design of my HSA compatible plan works.  The plan requires that I meet the first $2,600 before BCBSIL is to pay 100% of all remaining calendar year expenses.  I take a monthly medication that costs $46 each time at Walgreens, totaling $552/year that is applied toward my deductible.  With the above ER expense I have applied a total of $1,129 toward the plan deductible.  This leaves me knowing that if anything major happened to me, I would only owe a remaining $1,471 before BCBSIL is to pay 100%.  For the price I pay in premium, I don't find a high deductible plan of coverage without copays to be too bad.

Hope this helps in making a decision towards purchasing a plan or understanding how a plan of coverage works.

Thanks,

-The Shoppe

sliw afternoon and vail kills time at the shoppe

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What does having a low deductible mean?

When referencing a low deductible it is in the line of $500 or $1,000.

These are most likely found when coverage is being provided through your employer.

Having a low deductible only means that you are paying a lower amount prior to your insurance carrier paying a percentage (coinsurance) in which you pay your percentage share towards the plans out-of-pocket expense limit in addition to your plans deductible.  Any copays do not apply to the plan deductible or out-of-pocket.

A lower deductible will come into play better than a high when looking at outpatient procedures that total from $500-$2,000

When faced with a large claim such as hospitalization than a low deductible plan will pay them same when comparing high deductible plans, $2,500 or above, especially with 100% coverage after the high deductible,  The main note is that the higher deductible plan can cost anywhere from 30-40% lower in monthly premium.

When choosing to pay the premium for a low deductible, the insured is making the choice in paying upfront to pay less at time of service.  When choosing a higher deductible, especially HSA compatible, the insured is saving in premium and self insuring themselves for small expenses such as office visits.

Please contact the shoppe with any questions.

-The Shoppe

Late night at the shoppe with vail

Awesome

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Check out The Shoppe on ABCs LiveWell HD

Please make sure to check out The Shoppe on ABCs LiveWell HD
http://bit.ly/livewellhd

Thanks for all your support!

vail

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