Understanding Health Insurance

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1 Understanding Health Insurance Health insurance can play an important role when it comes to medical bills and prescription medications it can help protect you from high expenses. There are many types of health insurance plans. This can sometimes make understanding health insurance difficult. The information below can help you make more informed decisions about health insurance. Because every health plan is different, you should speak directly to the health insurance plan provider if you have any questions or concerns. Ways to get health insurance Health insurance can be obtained in 1 of 2 ways: through a group or individually. 1. Group health insurance Group health insurance might be offered to you through employers or organizations, such as unions or professional associations, to which you may belong. 2. Individual health insurance If you do not have access to group insurance, you may choose to purchase individual health insurance directly from an insurance company. Many people get individual health insurance through government programs such as Medicare and Medicaid if they are eligible. Types of health insurance 1. Indemnity insurance Also known as fee-for-service or traditional health insurance, indemnity insurance plans usually allow members to see the health care professionals and hospitals of their choice. Indemnity insurance plans pay only part of the medical bills for you. Usually, you will need to spend a certain amount each year before the plan begins to pay benefits. This amount is called a deductible. Indemnity policies typically have an out-of-pocket maximum, so once expenses reach a certain amount in a given calendar year, the remaining cost usually will be paid in full by the plan. 2. Managed care plans An alternative to indemnity health insurance plans, managed care plans allow members to select from participating health care professionals and hospitals. With managed care plans, costs tend to be lower when patients use participating health care professionals. Each time you go to a health care professional or hospital, or fill a prescription, you will usually need to pay a co-pay. The amount of the co-pay will vary.

2 There are 3 types of managed care plans: health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service (POS) plans. What Are Medicare and Medicaid? Medicare and Medicaid are 2 government programs that provide health insurance coverage to those who qualify. In general, what are the differences between HMO, PPO, and POS plans? HMO You select a primary care physician from the HMO network Requires all doctors you see to be within the HMO network Requires referrals for specialists and must be in the HMO network Co-pay amount varies PPO You choose to use a network or out-of-network doctor; you typically pay more for out-of-network visits and may need to pay for the treatment and submit the receipt to the insurance company for reimbursement Co-pays for out-of-network doctors tend to be more expensive than in-network Referrals for specialists are not usually required POS Combines features of HMO and PPO You choose a primary care physician (PCP) from the POS network Care provided by in-network doctors with a referral from your PCP You usually have the option to receive care outside the network without a referral from your PCP Medicare Medicare is the federal health insurance program for people aged 65 and older, some disabled Americans, and individuals who have end-stage renal disease. It has 4 parts A, B, C, and D. Part A Hospital insurance helps pay for inpatient hospital care, short-term care in skilled nursing facilities, hospice care, and some home health care. Part B Medical insurance helps pay for medical care, including doctor visits, outpatient hospital care, as well as medically necessary services, such as physical or occupational therapy. Part C Also known as Medicare Advantage, provides the option to obtain Parts A, B, and D benefits through private insurance. Part D Prescription drug coverage helps pay a portion of prescription drug costs. Medicaid Medicaid is a federal-state program that helps provide health care coverage for people with limited income. Coverage and eligibility vary by state. What is Medigap? Because Medicare does not cover all medical expenses, you may want to consider purchasing a Medigap policy. Medigap is private insurance that helps cover some of the gaps in Medicare benefits. For more detailed information about Medicare, Medicaid, and Medigap, contact: Centers for Medicare and Medicaid Services cms.hhs.gov State Health Insurance Assistance Program (SHIP) shiptalk.org Medicare 800-MEDICARE ( ) medicare.gov

3 Choosing the right policy When choosing the right health insurance policy, you may find it helpful to use medical and insurance records from last year as a guide to what you may use or need this year. Add up actual costs and premiums, and estimate expenses for services that are not covered. The following chart can help compare features for up to 3 different health plans: Questions to Ask Policy 1 Policy 2 Policy 3 What is the monthly premium? Individual Family Individual Family Individual Family Multiply by 12 for total annual cost: What is the deductible (if there is one)? Individual Family Individual Family Individual Family What is the coinsurance rate or co-pay, if there is one? (Note if there is a higher rate for special services such as outpatient mental health care.) Are there any annual limits for days or services covered and the amount spent? What is the maximum out-of-pocket amount you will have to pay each year? What is the lifetime limit, if any? Total estimated yearly cost: Mark the services that are covered with a 4: Hospital care Surgery (inpatient and outpatient) Office visits Maternity care Well-baby care Immunizations Mammograms X-rays Mental health care Vision care, eyeglasses, and exams Dental care, braces, and cleaning Prescription drugs Home health care Nursing home care List services you need, but are excluded Mark other important considerations with a 4: Choice of health care professionals Convenient location of health care professionals and hospitals Minimal paperwork Waiting period before coverage begins Coverage for preexisiting conditions Understanding Disability Insurance What is disability insurance? If you have an accident, illness, or injury that prevents you from working, having disability insurance can be helpful. Disability insurance can protect income just like other insurances protect a person s car or home. This insurance can help replace a portion of income when you are out of work. What does disability insurance cover? Disability insurance benefits can be used to help pay for everyday living expenses such as rent, utilities, or groceries. It does not cover the costs associated with rehabilitation following an injury or illness. What types of policies are available? There are 2 types of disability insurance: short term and long term. 1. Short-term disability insurance With short-term disability insurance, a person generally must wait up to 14 days after becoming disabled before receiving benefits, depending on the policy. Short-term disability insurance can help replace a portion of income for up to 2 years. 2. Long-term disability insurance With long-term disability insurance, a person generally must wait several weeks to several months after becoming disabled before receiving benefits. Long-term disability insurance can help replace a portion of income from a few years to a lifetime. Features of disability insurance It s important to know about 2 different protection features when purchasing disability insurance: noncancellable and guaranteed renewable. 1. Noncancellable Noncancellable means that the policy cannot be cancelled by the insurance company for any reason other than missed payments. 2. Guaranteed renewable Guaranteed renewable means that the policyholder can renew the policy with the same benefits, though premiums may increase. If an increase in premiums does occur, it must occur for similar policyholders as well.

4 Other options to consider In addition to the basic disability insurance policy, there are several other options to consider. These include: Option Additional purchase options Coordination of benefits Cost of living adjustment (COLA) Residual or partial disability rider Return of premium Waiver of premium provision What it means The insurance company gives the policyholder the right to purchase additional insurance at a later time. The amount of benefits received from the insurance company depends on other benefits received because of the disability. The policy specifies the total amount received from all policies combined. It makes up the difference not paid for by other policies. COLA increases disability benefits over time to reflect the cost of living. This often comes with a higher premium. This allows the policyholder to return to work part-time, collect part of his or her salary, and receive a partial disability payment. Requires the insurance company to refund part of the premium if no claims were made during the time frame specified in the policy. The policyholder does not have to pay premiums on the policy after being disabled for 90 days. How to purchase disability insurance Some people receive group disability insurance through their employer. Others may need to purchase disability insurance through a private insurance agent. Social Security also may provide disability benefits, based on salary and number of years worked. For more information, visit ssa.gov/disability/. How much does disability insurance cost? When it comes to cost, no 2 policies are the same. Some offer premiums that stay the same for the term of the policy, while others have rates that increase with a person s age. That s why it s important to carefully weigh a plan s features and benefits when selecting a policy. Important things to know All policies define disability differently. It s a good idea to make sure that your disability insurance covers the things you need. Also make sure that the policy cannot be cancelled and that renewals are guaranteed as long as premiums are paid on time and in full. If the policy cannot meet these conditions, you may want to shop around for a plan that better suits your needs. Understanding Long-Term Care Insurance What is long-term care insurance? Long-term care insurance can help pay for medical, personal, and social services for people with chronic or disabling conditions. People who qualify for long-term care usually require nursing care or constant supervision. Who might consider long-term care insurance? Keep in mind that long-term care insurance is not for everyone. It can be costly and can come with lots of restrictions. Still, long-term care insurance can be an important option to consider when preparing for the future. If you develop a health condition that requires long-term care and you do not have long-term care insurance, you may have to pay the entire cost of long-term care out of pocket, which can be a huge financial burden. Long-term care is not usually covered by traditional health insurance plans. Medicare generally does not cover long-term care either. Age and any health conditions you have can affect eligibility and cost. Where can a person receive long-term care? You can receive long-term care at home, or in an adult day care center, an assisted living facility, or a nursing home. How does a person purchase long-term care insurance? Long-term care insurance can be offered through an employer. Or you may be eligible for coverage through a union, fraternal group, or other organization to which you belong. In addition, many insurance companies offer individual long-term care insurance. Factors to consider Long-term care insurance plans vary from policy to policy. There are lots of factors to consider. These include: Coverage Factor Daily or monthly benefit Benefit period Elimination or waiting period Inflation protection Nonforfeiture benefit Why it matters Some policies cover nursing home care. Others may only cover home care. It s important to find out which services are covered. The daily or monthly benefit is the amount of money the insurance company will pay for each day or month a person is covered. The benefit period is the length of time in which a person will receive benefits. Elimination or waiting period is the amount of time a person must pay long-term care expenses out of pocket. The longer the waiting period, the lower the premiums are likely to be. Health care costs tend to rise each year. Inflation protection helps manage the rising costs of long-term care. Policies with a nonforfeiture benefit will continue to pay for long-term care even if a person stops making payments. This feature can add to the premium. Important things to know It s always a good idea to shop around for a long-term care insurance policy. Compare features and benefits, as well as cost. Never pay an insurance agent in cash write a check directly to the insurance company. This can help protect against fraud. Keep in mind that a free look clause allows you to review a long-term care insurance policy and cancel it within a certain number of days. Contact your state insurance commission for specific details.

5 Understanding Life Insurance What is life insurance? Why might it be needed? Life insurance can provide financial support to designated beneficiaries after your death. Life insurance also can provide money to help pay for outstanding expenses. This includes things such as mortgages, loans, and funeral costs. There may be other reasons to consider life insurance as well. How much life insurance is needed? There is no single answer when it comes to determining life insurance needs. Every person and situation is different that s why it s important to compare different policies and premiums. Many Web sites have online tools that can help you estimate your coverage needs. Another way to determine coverage is to speak with a life insurance representative directly. He or she may be able to help guide you when it comes to making decisions about life insurance. Ways to obtain life insurance There are 2 ways to obtain life insurance: through a group or individually. 1. Group life insurance Group life insurance is purchased through a group such as an employer, union, or organization. Group life insurance tends to be less expensive than individual life insurance, because of group rates. 2. Individual life insurance Individual life insurance is purchased through a private insurance company. Types of life insurance policies There are 2 types of life insurance policies: term and permanent. 1. Term life insurance Term life insurance covers a person for a specific amount of time, or term. Term policies will pay benefits only if the person dies during the term of the policy. 2. Permanent life insurance As long as payments are made on time, permanent life insurance covers a person permanently until death. Permanent life insurance may provide a savings feature that builds in value, allowing you to take out money. Permanent life insurance tends to be more expensive than term insurance. Which type of life insurance is best? When deciding between term and permanent life insurance, there are a lot of factors to consider. To help determine which type of coverage might benefit you, you may want to talk to an insurance agent directly. Important Insurance Terms Co-pay: The flat fee a person must pay each time he or she receives medical care. For example, a person may need to pay $10 each time he or she visits a health care professional. The health insurance plan pays the rest. Deductible: The amount a person must pay each year before the plan begins paying. Disability insurance: Pays benefits if a person becomes injured or seriously ill and is no longer able to work. Fee-for-service insurance: Also known as traditional or indemnity health insurance. Plan members must pay a portion of their health expenses, usually after meeting a yearly deductible. Group health insurance: Health plans offered to a group of individuals by an employer, association, union, or other entity. Health maintenance organization (HMO): A form of managed care in which a person receives all of his or her care from participating providers. He or she usually must obtain a referral from a primary care physician before seeing a specialist. Indemnity insurance: Traditional, fee-for-service health insurance that does not limit where a covered individual can get care. Individual health insurance: Coverage purchased independently (not as part of a group), usually directly from an insurance company. Life insurance: Provides financial support to designated beneficiaries, such as family members or friends, after a person has died. Long-term care insurance: Coverage that pays for all or part of the cost of home health care services, as well as care in a nursing home or assisted living facility. Managed care: An organized way of getting health care services and paying for care. Managed care plans feature a network of health care professionals, hospitals, and other providers who participate in the plan. In some plans, covered individuals must see an in-network provider; in other plans, covered individuals may go outside of the network, but they will pay a larger share of the cost. Medicaid: A federal program administered by the states to provide health care for certain poor and low-income individuals and families. Eligibility and other features vary from state to state. Medicare: A federal insurance program that provides health care coverage to individuals aged 65 and older and certain disabled people, such as those with end-stage renal disease. Network: A group of physicians, hospitals, and other providers who participate in a particular managed care plan. Out-of-pocket expenses: Amount that a person needs to contribute toward the cost of health services, such as co-payments and deductibles. Point-of-service (POS) plan: A form of managed care plan in which primary care physicians coordinate patient care. Allows for more flexibility in choosing health care professionals and hospitals than an HMO. Preexisting condition: A health condition or medical problem that was diagnosed or treated prior to enrolling in a new health insurance plan. Preferred provider organization: A form of managed care that allows for more flexibility than an HMO in choosing health care professionals and other providers. Plan members can see both participating and nonparticipating providers, but out-of-pocket expenses will be lower when seeing participating providers. Premium: The amount a person pays to belong to a health plan. If he or she has employer-sponsored health insurance, premiums usually are deducted from a person s pay. Primary care physician (PCP): Usually a family practice doctor, internist, obstetrician-gynecologist, or pediatrician. He or she is usually the first point of contact with the health care system. Referral: Directions or instructions given by a primary care physician directing a person to see another health care professional or receive other health care services. Referral also can mean the written authorization for such a visit. Sources: Aetna, Financial Planning Association. Plan for your health. Glossary. planforyourhealth.com/tools-resources/glossary/. Accessed October 18, Agency for Healthcare Research and Quality. Glossary. archive.ahrq.gov/consumer/insuranceqa/qaglossary.htm. Accessed October 18, Merriam-Webster Online Dictionary. Life insurance. merriam-webster.com/dictionary/life+20insurance. Accessed October 17, 2011.

6 Copyright 2011 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. All rights reserved. NOND /11 MerckEngage.com

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