Your guide to all your health insurance needs

Presented By:

Cost of Health Insurance1. Dramatically Rising

New Technology / Equipment

Rx costs

Covering the Uninsured

Hospital Costs

Shift - Types of insurance & Cost Sharing by Employers

3

Styles of Health InsuranceHMO: Health Maintenance Organization

PPO: Participating Provider Organization

HDHP with HSAs: High Deductible Health

Plan that may be paired with the financial

product, a Health Saving Account.

Definitions used in Health Insurance Copays:

Deductible:

Coinsurance:

OOP (Out of Pocket Maximum):

Life Time Maximum

Dollar amount that offsets partially the cost of medical care

Dollar amount to be paid for medical services before insurance coverage engages

Percentage or cost sharing of medical expense after deductible is met.

Maximum amount to be paid by enrollee before insurance covers expenses fully

The maximum liability that the policy will cover

Definitions Continued…

Rx 15/35/50/30% Generic Brand Name Non – Formulary Self injectibles

The categories have been changing

Example of an HMO

Example of an PPO

Example of HSA Eligible

Health Savings AccountsBank Account paired with H.D.H.P

Employers and /or Employees can fund the account

Account is owned by the employee or individual who

is primary on the health insurance

Tax Deductible Contribution –

Tax Free Withdrawals – Eligible Medical Expenses

Other StylesIndemnity: Traditional format with no in or

out of network contract

Limited Benefit: Newer Major Medical that

may cover only some hospitalization, ER

visits, and limit OOP and/or lifetime

maximums

Non Insurance Discount Programs

Network Plans

Promise – Can’t Be Turned Down

Office Visit??

Rx Covered ???

What’s Left Out????

Definitions Continued…Preventative:

Diagnostic:

Annual, nationally listed care for children & adults, i.e., immunizations, mammograms, PSA

Treatment or testing for existing conditions

Definitions Continued…Behavioral Health

Mental Health, Substance Abuse, Alcohol Abuse

Limited Benefits - inpatient 45 days / yr. outpatient 20 visits/ yr. detox – 3 days

Substance Abuse – very limited benefitsParity - treat mental health at the same level

as physical health -State Reg - Biologically Based Mental Illness –

ParityReality Check

Available Health Insurance Coverage

1. Individual and Family Plans

2. Short-Term Health Insurance- 30 days to 6

months

3. Employer Sponsored Plans

4. Medicare / Medicaid/ Cover Colorado/ CHP

Individual and Family Plans

Eligibility based on health underwriting

Lower Cost - due to a healthier population

Paid by the individual

Health Issues Riders

Rate ups

Decline

Short Term Health InsuranceImmediate Coverage –PPO

Major Med for Hospital & ER

30 days to 6 months

Can be declined for pre-existing conditions

Do not cover pre-existing conditions

Good for the gap between becoming eligible

at a new job, or recent university grads

Employer Sponsored Plans Small Group Plans

Business Group of One

2-50 Employees

Large Group Plans

51 + Employees (some carriers consider

>100)

Employer Sponsored PlansBusiness Group of One (BGO)

Guaranteed Issue

State Mandated Plans

Standard & Basic HMO & PPO plans

Indemnity Plans

Open Enrollment periods

Proof of Business

Employer Sponsored PlansSmall Group 2-50 employees

Guaranteed Issue

Proof of Business Rates Based Upon Plan Design, Age, SIC Code and

Tobacco Usage

State Mandated Coverages

Basic plans – stripping out some of the preventative

Table Rates or Composite Rates

Example Rate Table

Employer Sponsored PlansLarge Group 51 + employees

Not Guaranteed Issue

Rates Based upon Health Experience, Age, and

Plan Design

SIC Code and Tobacco Usage Play a part in the

rates.

Larger Groups - rates are Negotiable

Proof of Business

Employer Sponsored Plans

Self Funded Plans share the risk with

employers Employer Pays Claims up to individual & group limits

TPA or Insurance Company Administers Claims

Stop Loss Limits - Cap Liability

Lower Initial Cost but Higher Risk

Enrollment EligibilityQualifying Events

Major Life Events, i.e., Birth, Adoption, Legal Guardianship, Marriage, Divorce, Death

Loss of coverage through no choice of your ownOpen EnrollmentNew Hires - waiting periodPre existing conditions

FraudSee Colorado Division of Insurance definitions

MIB (Medical Information Bureau)Like a credit bureau, has records of your medical history,

and can be checked annually for accuracy to control ID theft. Also IntelliScript checks for filled prescriptions.

HIPPAHealth Insurance Portability and Accountability

Act,PrivacyRight to Convert

COBRA/ State ContinuationCOBRA is federal law mandating the right to

temporarily continue group health coverage for a period of time

State Continuation is state law to fill in gaps left by COBRA for employee groups with less than 20 employees

COBRA/ State Continuation

New Federal Regulation : Federal Government will subsidize 65% of Premium for up to 9 Months.

If Business Fails - COBRA ends

New COBRA RegulationsFor involuntary loss of employment onlyLoss of employment from 9/1/08 to 12/31/09If from 9/1/08 to present you have had employees

eligible for COBRA must contact them with the new eligibility period (from 2/17/09 for 60 days forward)

Starting 3/1/09 employees that elect this coverage will pay 35% of the premium.

Starting 3/1/09 employers of these electees will pay 65% to be reimbursed on their payroll taxes.

End of COBRA or Continuation

Conversion or CoverColoradoThe right to convert a group health insurance

policy after completion of COBRA, being ineligible for individual health insurance due to significant pre-existing conditions. Premiums may be up to 2.5 times of normal

CoverColorado is our state’s “uninsurable risk pool”, providing insurance for those who are declined individual health insurance coverage or who have certain listed conditions

Web Access

Health Resources Access health and

wellness information.

Health Extras Maximize opportunities

for better health.

Health Guidance Get help when in need of

care.

Health Management Receive ongoing

management and help coordinating your care.

We’ve designed a broad spectrum of health services to meet the needs of your total member population.

Anthem Blue Cross 360º Health Services Overview

MyHealth@AnthemMembers will have their own, personalized health resource center on the web. Healthy Living offers interactive tools to help your employees assess, manage and improve their health.

Sections include: Children’s Health News Men’s Health Women’s Health Mental Health Alternative Medicine Daily Health Tips

Healthy Living provides timely, trusted and personalized information to engage members

Anthem Blue Cross360º Health Resources

Web AccessEmployers

Real time access for HR to manage enrollments and terminations of employees, and billing

MedicarePart A- Hospitalization: entitled to premium-free

enrollment if you or your spouse paid Medicare

taxes

Part B- Doctor and lab coverage: Income based

premium from SS check or self paid

Part D- Rx coverage

Medicare Continued…Medicare Advantage Medicare SupplementsSometimes referred to

as Medicare Part C, a hybrid of Part A, B, and D that are assigned to the carriers

Uses contracted doctors and hospitals only

Useful outside of contract area only in emergencies

Kaiser, Secure Horizons

Also called Medigap plans, originally had 10 plan levels

Need to purchase Medicare Part D coverage for RX needs

Has in and out of network benefits, so it travels better for “snowbirds”

AARP - United

Medicare Continued…Group Size determines whether Medicare is

Primary or Secondary in paying claimsSecondary coverage acts as Medicare “supplement”Medicare Eligible cannot contribute to funding

HSAsSome disabilities before age 65 are Medicare

eligibleCarriers must annually report enrolled Medicare

persons on group plans to be in compliance with new law. Employer groups will need to share SS# of people that are Medicare eligible.

Colorado Division of InsuranceConsumer Protection is their mission

Source of consumer information

Performs market conduct and financial exams on

insurance companies

File consumer complaints online or call 303-894-

7490