What is a census and why do you need it?
A census is a simple form listing all employees, their ages, marital status, etc. It is used to provide the insurance carrier with the information necessary to generate an accurate quote.
What is Insurance?
Insurance is a contract that allows parties to share risk. Basically, a person pays their Premiums in exchange for the Insurance Company's commitment to pay a predetermined amount of money for any or all problems (Claims).
What is a Deductible?
It is a predetermined amount of money that a person commits to pay before the Insurance Company is responsible for any benefit payments. This is done so that people will make sure that any problem that an insured might have really needs medical assistance. It is a way for Insurance Companies to keep premium costs down.
What is a "Doctor's Office Visit Copay"?
Generally, this is an amount of money that an insured patient would pay to their doctor for that particular visit. In most cases, any costs incurred in that visit are covered 100% after the copay. Often, any lab tests (MRIs, Blood work ups, etc.) are not included in that visit cost and are subject to Deductibles and Coinsurance.
Do I have to pay my deductible before "Office Visits" are covered by copays?
The simple answer is no. However, there may be companies that do have that clause in their contracts. It wouldn't be against the law to have that clause, but we rarely see this situation.
What is Coinsurance?
Coinsurance is the portion of medical costs that are shared by both the Insured (the patient) and the Insurer. For example, if you have an 80% to $5,000 coinsurance;
~ The Insurer is responsible for 80% of the next $5,000 in covered medical expenses.
~ The Insured is responsible for 20% of that same $5,000 in covered medical expenses.
* In the above mentioned policy with $1,000 deductible and 80% coinsurance to $5,000: If a covered event occurred that had a total cost of $10,000, the insured would be responsible for the first $1,000 (deductible). Of the next $5,000 in covered expenses, the insured would pay another $1,000 (coinsurance). After deductibles and coinsurance are satisfied, Insurance Companies pay 100% of all other covered expenses. For this example the Insured would pay $2,000 and the Insurer would pay $8,000.
Are copayments credited against my annual deductible requirements?
No, for the most part, insurance policies with "Office Visit Copays" handle office visits and hospital stays differently. Hospital stays are generally covered under the "Major Medical" portion of the policy and tend to be subject to deductibles and coinsurance.
What is the difference between "Group" and "Individual" coverage?
A simple explanation is that group policies can include two families or more and require an employer to pay a minimum of 50% or the single person premium to qualify. Individual policies cover only one family or individual.
Can I be charged more for a policy than a nonsmoker would because I smoke?
No. Insurance companies can only choose to accept or reject your application based on smoking or any physical impairment.
Can I be singled out for cancellation of a policy because of health problems?
No. You can, however, use up your benefits by having covered expenses in excess of your lifetime maximums.
Does it cost me more to deal with an agent than it would if I dealt directly with an Insurance Company?
No. In dealing with an agent, you are dealing with the Insurance Company. Agents are appointed (approved) by insurance companies and are required to fairly and accurately represent them. There are no extra fees to be paid to us for our services. The benefit of dealing with an agent who represents several companies is that you get an even analysis of each company's products and options.
What is Group Insurance?
Generally, Group Insurance is defined as a policy that an employer makes application for with an Insurance Company. The employer is generally required to pay some portion of the employees' premium and the employee must work some minimum number of hours per week. The employer can pay a greater portion of the premium, but is not required to do so. In some states, Group Insurance is "Guaranteed Issue". which means that the Insurance Company cannot turn down any applicant.
Are any benefits required by law?
Employers must provide certain benefits to employees in compliance with federal and state laws. These benefits are commonly referred to as "statutory" or government-mandated benefits. They include:
•Social Security and Medicare; •Workers' compensation; •Short-term disability (in certain states); •Unemployment compensation; •Time off to vote; •Time off to serve as a juror if summoned by a court; •Time off for military duty; •Time off for family and medical leave purposes; and •Accommodation of religious observance
What types of "voluntary" benefits are available?
Many employers voluntarily provide employees with additional fringe benefits that are not required by law. These can range from paid time off for vacations, sick days and holidays, to free parking and the like. Such benefits can often be more cost-effective than simply offering additional salary.
What is a cafeteria or flex plan?
In order to allow employees to purchase the benefits that they most value, many employers establish flexible benefit or cafeteria plans. With a cafeteria plan, employees are allocated an "allowance" - a specific amount of premium payments - for the purchase of benefits and an array of benefit options from which to choose.
Are all businesses subject to the Family and Medical Leave Act?
Medical leaves of absence, often referred to as disability eaves, are
generally longer leaves, during which the employer does not continue to pay
salary but does hold the employee's job.
Who can contribute to a Health Savings Account?
Contributions to HSAs can be made by either the employer or the individual, or both. If contributions are made by the individual, it is an "above-the-line" deduction. If contributions are made by the employer, it is not taxable to the employee (excluded from income). Contributions can also be made by others on behalf of an eligible individual and deducted by the individual. All contributions are aggregated.
Do Health Savings Account funds roll over year after year and get invested?
Yes, the money invested in a Health Savings Account rolls over year after year.
What life insurance options are available to an employer?
Most employers provide some form of life and disability insurance to cover their employees. Benefits are relatively inexpensive to obtain at group rates available to the employer and are usually based on the employee's salary.
What Are the New HIPAA Privacy Rules?
The privacy provisions of HIPAA apply to health information created or maintained by health care providers who engage in certain electronic transactions, health plans, and health care clearinghouses. The Department of Health and Human Services (HHS) has issued the regulation, "Standards for Privacy of Individually Identifiable Health Information," applicable to entities covered by HIPAA. The Office for Civil Rights (OCR) is the Departmental component responsible for implementing and enforcing the privacy regulation. (See the Statement of Delegation of Authority to the Office for Civil Rights, as published in the Federal Register on December 28, 2000.)
The privacy standards contain three basic sections:
1.Restriction on the use and disclosure of certain health information; 2.Establishment of individual rights regarding health information; and 3.Establishment of administrative requirements to ensure confidentiality and appropriate use of health information.
The regulations are often confusing, compliance will be difficult, and the consequences for non-compliance can be unpleasant; there are both civil and criminal penalties for violations. So, a basic understanding is essential for compliance.
What Is PHI?
Information protected by the HIPAA privacy regulations is called "personal health information" or PHI. For uses of PHI, the policies and procedures must identify the persons or classes of persons within the covered entity who need access to the information to carry out their job duties, the categories or types of PHI needed, and conditions appropriate to such access. For example, hospitals may implement policies that permit doctors, nurses, or others involved in treatment to have access to the entire medical record, as needed. Case-by-case review of each use is not required. Where the entire medical record is necessary, the covered entity's policies and procedures must state so explicitly and include a justification.
For routine or recurring requests and disclosures, the policies and procedures may be standard protocols and must limit PHI disclosed or requested to that which is the minimum necessary for that particular type of disclosure or request. Individual review of each disclosure or request is not required.
For non-routine disclosures, covered entities must develop reasonable criteria for determining, and limiting disclosure to, only the minimum amount of PHI necessary to accomplish the purpose of a non-routine disclosure. Non-routine disclosures must be reviewed on an individual basis in accordance with these criteria. When making non-routine requests for PHI, the covered entity must review each request so as to ask for only that information reasonably necessary for the purpose of the request.
