Sometimes eating an apple a day is, unfortunately, not enough to keep the doctor away. Your health is your single biggest asset, protect it as such. It’s easy to get consumed with day-to-day life and taking care of our health falls by the wayside. Taking small steps, such as eating a healthy, well-balanced diet, exercising and having annual check ups can help you live a healthier, longer life.
Preventative care, and its corresponding coverage, is equally as important as having coverage in the event of an emergency. A good health insurance plan should include both coverage for preventative care and coverage in the event of an emergency. Preventative care can be costly but with the right insurance you don’t have to break the bank to ensure you’re in tiptop shape!
Here at Envision Insurance (located in Sterling Heights, Michigan) we have a team of highly trained, licensed insurance professionals ready to help with determining what coverage is most appropriate for you and your family.
Listed below is a brief explanation of various types of federal and Michigan health insurance coverages to help you gain a better understanding of what your federal and Michigan health insurance policy may cover. This list is not comprehensive and determining what coverage is right for you and your family’s unique situation should be left to the experts. Call us today with your questions on which coverage is most appropriate for you and ask us for a free quote!
Recent Changes in Health Insurance Regulation:
Health insurance has been in the crosshairs of politicians and legislators, for nearly a decade, with reform at the forefront of their priorities. Health insurance is provided by both private and non-profit corporations as well as through government aid programs (such as Medicare and Medicaid).
The Patient Protection and Affordable Care Act of 2010 (also known as Obamacare) was enacted to:
Reduce the cost of health insurance coverage
Make having health insurance mandatory (or to make a shared responsibility payment when you file your federal income tax if you elect you do not want health insurance coverage)
Mandate health insurance carriers to accept people with pre-existing conditions
Provide subsidies (government grant / financial aid) to low-income individuals and families
Obamacare faced much criticism in the years after it was enacted and, although it wasn’t ultimately repealed, many changes have been made, including:
Repealing the individual mandate for having an active health insurance plan or otherwise being penalized with a shared responsibility payment
Allowing for small businesses to offer Association Health Plans (AHPs) which are short-term plans that allow higher premiums for coverage to individuals with pre-existing conditions, or for coverage to be denied altogether. This was made illegal for long-term plans under Obamacare
Shortening enrollment periods from 90 days to 45 days
Ending cost-sharing reduction (CSR) payments, while keeping intact many healthcare subsidies for low-income Americans
Frequently Asked Questions:
What is the difference between insurance plans offered on a marketplace vs purchasing private insurance?
A health insurance marketplace is a place where you can shop and sign up for affordable health insurance plans. A marketplace is sometimes called “the exchange.” Marketplaces sell health insurance policies that may be subsidized by the federal government, depending on your income and family size. If you qualify for a subsidized plan, your costs for health insurance premiums will be reduced.
Not all marketplaces are run by the government. There are federal and state government marketplaces as well as private marketplaces. In order to purchase health insurance through a marketplace you must be a U.S. citizen or national who currently lives in the United States and is not incarcerated nor currently covered by Medicare.
Private insurance, however, is health insurance offered directly through a health insurance carrier (company). You may call the carrier directly or purchase a plan via their website. There are several dozen insurance carriers offering many of the same types of plans (see Types of health Insurance Plans below for more details).
Is it cheaper to purchase health insurance through a marketplace or private insurance?
Low-income Americans may receive subsidies from the government if they meet certain income thresholds and depending on the size of their family. For individuals and families who qualify for these subsidies it is cheaper to purchase a health insurance plan through a marketplace, as only marketplaces offer plans that includes subsidies (granted they have direct enrollment agreements with CMS).
What is open enrollment?
Open enrollment is the yearly period when individuals (and families) can enroll in a health insurance plan. Currently, the enrollment period opens on November 1st and ends on December 15th. Medicare open enrollment runs from October 15th to December 7th each year.
Where can I purchase a health insurance plan from?
Envision Insurance is here to help you with all of your health insurance needs. We have a highly-trained team of insurance professionals ready to answer any questions you may have or help you with purchasing a health insurance plan for yourself and / or your family. We can be reached at 248-509-4883.
However, if you believe you qualify for government subsidies you should consider visiting a marketplace such as www.HealthCare.gov.
What is a Qualifying Life Event (QLE)?
A qualifying Life Event (QLE) is a change in your situation – like getting married, having a baby, or losing health coverage – that can make you eligible for a Special Enrollment Period, allowing you to enroll in health insurance outside the yearly Open Enrollment Period.
There are 4 basic types of qualifying life events (the following are examples, not a full list):
Loss of Health Coverage
Losing existing health coverage, including job-based (group health), individual and student plans
Losing eligibility for Medicare, Medicaid or CHIP
Turning 26 and losing coverage through a parent’s plan
Changes in Household
Getting married or divorced
Having a baby or adopting a child
Death in the family
Changes in Residence
Moving to a different ZIP code or county
A student moving to or from the place they attend school
A seasonal worker moving to or from the place they both live and work
Moving to or from a shelter or other transitional housing
Other Qualifying Events
Changes in your income that affect the coverage you qualify for
Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
Becoming a U.S. citizen
Leaving incarceration (jail or prison)
AmeriCrops members starting or ending their service
Can I purchase private insurance outside the enrollment period if I do not have a qualifying life event?
Much like health insurance purchased through a marketplace, you cannot purchase a private health insurance plan outside the open enrollment period unless you have a qualifying life event (as listed in the above section) which would qualify you and your family for a special enrollment period in which time you have 60 days following the event to enroll in a plan.
What are deductibles and out-of-pocket costs?
Deductible: How much you have to spend for covered health services before your insurance company pays anything (except free preventive services).
Copayments and coinsurance: Payments you make each time you get a medical service after reaching your deductible.
Out-of-pocket maximum: The most you have to spend for covered services in a year. After you reach this amount, the insurance company pays 100% for covered services.
What is Coordination of Benefits?
Coordination of Benefits is when two insurance companies work together to pay claims for the same person. In other words, if you are insured by two different insurance carriers for health insurance then they work in tandem to cover any claim you may file. Insurance companies coordinate benefits to:
Avoid duplicate payments by making sure the two plans don’t pay more than the total amount of the claim
Establish which plan is primary and which plan is secondary – that is, the plan that pays first and the plan that pays any remaining balance after your share of the costs is deducted
Help reduce the cost of insurance premiums
How does Coordination of Benefits relate to my no-fault auto insurance?
If you have a health insurance coverage that pays primary for injuries resulting from a car accident then your health insurance carrier will be first to pay for any auto-accident related medical expenses. Once your health insurance coverage is exhausted (pertaining to the auto accident) then your auto insurance carrier’s Personal Injury Protection (PIP) coverage will then begin to pay for these expenses.
Types of Health Insurance Plans:
Individual & Family
Individual and family health insurance plans can be purchased through a marketplace, as described above, or privately (directly) through a health insurance carrier. If you elect to purchase your health insurance directly through a health insurance carrier, you may decide to deal with a local independent agent / agency. A benefit of a local agent is having one agent (or a small team of agents) who knows you and your family’s unique situation and can custom tailor a plan geared to cover your needs.
Regardless of how you elect to purchase your health insurance policy or where you elect to purchase it from - there are several different types to choose from. Outlined below are a few popular types of individual and family health insurance:
Fee-for-Service (Traditional Indemnity Plans) – A type of health plan where you may choose your doctors, hospitals and other health care providers. You do not need a referral to see a specialist. The insurance company doesn't get to decide whether the visit was necessary. Under fee-for-service plans, insurers will usually only pay for reasonable and customary" medical expenses, taking into account what other practitioners in the area charge for similar services. Fee-for-service coverage offers flexibility in exchange for higher out-of-pocket expenses, more paperwork and higher premiums.
EPO (Exclusive Provider Organization) - A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).
PPO (Preferred Provider Organizations) - A type of health plan where you pay less if you use providers in the plan’s network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.
POS (Point-of-Service) - A type of plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans require you to get a referral from your primary care doctor in order to see a specialist.
HMO (Health Maintenance Organizations) - A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
HSA (Health Savings Account) - A type of savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses. By using untaxed dollars in a Health Savings Account (HSA) to pay for deductibles, copayments, coinsurance, and some other expenses, you can lower your overall health care costs.
An HSA can be used only if you have a High Deductible Health Plan (HDHP) — generally any health plan (including a Marketplace plan) with a deductible of at least $1,350 for an individual or $2,700 for a family. When you view plans in the Marketplace, you can see if they’re "HSA-eligible."
For 2018, you can contribute up to $3,450 for self-only HDHP coverage and up to $6,900 for family HDHP coverage. HSA funds roll over year to year if you don't spend them. An HSA may earn interest, which is not taxable.
Some health insurance companies offer HSAs for their high deductible plans. Check with your company. You can also open an HSA through some banks and other financial institutions.
Group Health (Employer)
A group health insurance plan is a health insurance plan that provides coverage to members of a group that tends to be employees of a company or members of an organization. The primary advantage of a group plan is that it spreads risk across a pool of insured individuals. This benefits the group members by keeping premiums low, and insurers can better manage risk when they have a clearer idea of who they are covering. Insurers can exert even greater control over costs through health maintenance organizations (HMOs), in which providers contract with insurers to provide care to members. The HMO model tends to keep costs low, at the cost of restrictions on the flexibility of care afforded to individuals. Preferred provider organizations (PPOs) offer the patient greater choice of doctors and easier access to specialists but tend to charge higher premiums than HMOs.
Most group health insurance plans are employer-sponsored benefit plans. It is possible, however, to purchase group coverage through an association or other organizations. Examples of such plans include those offered by the American Association of Retired Persons (AARP), the Freelancers Union and wholesale membership clubs.
What's the difference between group and individual coverage?
Health insurance provided to employees by an employer or by an association to its members is called group coverage.
Health insurance you buy on your own—not through an employer or association—is called individual (or family) coverage.
Those are the basics. But what does it mean for you if you're changing from group coverage to individual? What will be different for you?
Group vs. individual coverage
If you've had employer-sponsored coverage, you're probably used to certain things. Your employer may:
Give you a choice of health insurance plans
Pay for all or some of your monthly premium
Deduct your share of your premium from your paycheck each pay period
Provide your plan documents
Answer questions about your plan
If for some reason you can't get coverage through your employer anymore, you'll still need a health plan. For many people, that means buying individual health insurance.
Unlike traditional employer-sponsored insurance, now you'll:
Shop for and choose a plan that covers you and your family
Purchase your plan
Make all monthly premium payments
Get to know and manage all of your health coverage and benefits
Depending on how many employees there are, benefits covered by group and individual plans may be different. All health plans for individuals and businesses with fewer than 50 full-time equivalent employees cover the same 10 essential health benefits (see list below). But, if your employer has 51 or more full-time equivalent employees, they have more say in what your plan does and doesn't cover.
List of Essential Health Benefits that All Employer Group Plans Offer*:
Maternity and newborn care
Mental health and substance use disorder, including behavioral treatment
Rehabilitative and habilitative services and devices
Preventative and wellness services and chronic disease management
*Employers with 50 full time employees or more have more discretion with what their group plan does and does not include – as such, there may be
Medicare is the federal health insurance program for:
People who are 65 or older
Certain younger people with disabilities
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)
Medicare coverage is based on 3 main factors
Federal and state laws.
National coverage decisions made by Medicare about whether something is covered.
Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.
The different parts of Medicare help cover specific services:
Medicare Part A (Hospital Insurance)
Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
Medicare Part B (Medical Insurance)
Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.
Medicare Part D (prescription drug coverage)
Part D adds prescription drug coverage to:
Some Medicare Cost Plans
Some Medicare Private-Fee-for-Service Plans
Medicare Medical Savings Account Plans
These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.
What’s not covered by Part A & Part B?
Medicare doesn't cover everything. If you need certain services Medicare doesn't cover, you'll have to pay for them yourself unless:
You have other insurance that covers them
You have a Medicare health plan that covers them
Some of the items and services that Medicare doesn't cover include:
Most dental care
Eye exams related to prescribing glasses
Hearing aids and exams for fitting them
Routine foot care
If you're in a Medicare Advantage Plan or other Medicare plan, you may have different rules. But, your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.
Medicaid is a joint federal and state program that, together with the Children’s Health Insurance Program (CHIP), helps with medical costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including children, pregnant women, parents, seniors, and individuals with disabilities, as well as nursing home care and personal care services. In other words, Medicare is a government insurance program for persons of all ages whose income and resources are insufficient to pay for health care. States have additional options for coverage and may choose to cover other groups, such as individuals receiving home and community-based services and children in foster care who are not otherwise eligible. According to Medicaid.gov there are 65.6 million Americans covered per the February 2019 Enrollment Report.
The Affordable Care Act of 2010 created the opportunity for states to expand Medicaid to cover nearly all low-income Americans under age 65. Eligibility for children was extended to at least 133% of the federal poverty level (FPL) in every state (most states cover children to higher income levels), and states were given the option to extend eligibility to adults with income at or below 133% of the FPL. Most states have chosen to expand coverage to adults, and those that have not yet expanded may choose to do so at any time.
The Affordable Care Act established a new methodology for determining income eligibility for Medicaid, which is based on Modified Adjusted Gross Income (MAGI). MAGI is used to determine financial eligibility for Medicaid, CHIP, premium tax credits and cost sharing reductions available through the health insurance marketplace. MAGI uses one set of income counting rules and a single application across programs and considers taxable income and tax filing relationships to determine financial eligibility for Medicaid.
To be eligible for Medicaid, individuals must also meet certain non-financial eligibility criteria. Medicaid beneficiaries generally must be residents of the state in which they are receiving Medicaid. They must be either citizens of the United States or certain qualified non-citizens, such as lawful permanent residents. In addition, some eligibility groups are limited by age, or by pregnancy or parenting status.
Effective Date of Coverage
Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application, if the individual would have been eligible during that period had he or she applied. Coverage generally stops at the end of the month in which a person no longer meets the requirements for eligibility.
States have the option to establish a “medically needy program” for individuals with significant health needs whose income is too high to otherwise qualify for Medicaid under other eligibility groups. Medically needy individuals can still become eligible by “spending down” the amount of income that is above a state's medically needy income standard. Individuals spend down by incurring expenses for medical and remedial care for which they do not have health insurance. Once an individual’s incurred expenses exceed the difference between the individual’s income and the state’s medically needy income level (the “spenddown” amount), the person can be eligible for Medicaid. The Medicaid program then pays the cost of services that exceeds the expenses the individual had to incur to become eligible.
States must provide individuals the opportunity to request a fair hearing regarding a denial, an action taken by the state agency that he or she believes was erroneous, or if the state has not acted with reasonable promptness. States have options for how to structure their appeals processes. Appeals may be conducted by the Medicaid agency or delegated to the Exchange or Exchange Appeals Entity.
Disclaimer: Please note, the information provided above is strictly for informational and educational purposes and should not be considered as legal and / or insurance counseling advice. If you have specific questions regarding a claim and / or lawsuit please seek proper legal counsel and representation. Insurance terms, definitions and explanations are intended for informational purposes only and do not in any way replace or modify the definitions and information contained in individual insurance contracts, policies or declaration pages, which are controlling. Such terms and availability may vary by state and exclusions may apply. Discounts may not be applied to all policy coverages.
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