FAQS

When do my dependent children have to get their own insurance?
What's an outline of coverage?
Is maternity coverage included?
Do I have to take a physical exam to get health insurance?
Do I need to see an agent to get health insurance?
What questions should I ask my agent?
Am I stuck with an annual contract?
Does my insurance cover me when traveling?
What if I'm on prescription medication?
Can I be canceled?
Can I be singled out for a rate increase?
What is a pre-existing condition and why does it matter?
What if I had a recent accident or illness?
What makes up an HSA Plan?
Why should I use an insurance agent to get health insurance?
What affects my cost of insurance the most?
What are usual customary and reasonable charges?
The doctor charged $3,500.00 for a medical procedure and insurance company only paid $2,000.00 because they say this is the UCR amount. Can they do this and do I owe the difference?
Can I buy a policy that does not pay according to UCR so that I will not have to pay the difference charged by the doctor and allowed by the insurer?
Is an HSA the best health insurance for everyone?

Forms

Approved IRS Expenses
To order IRS Publication 502, call 1-800-TAX-FORM

Glossary

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Q: When do my dependent children have to get their own insurance?

A: If they're a full-time student it's age 25. Otherwise check your outline of coverage. It could be as young as 18 if they have moved out of the house and are no longer a dependent.

Q: What's an outline of coverage?

A: It's the document that explains what is and what isn't covered. Yes, you should read it. Yes, you should ask your insurance agent to review it with you.

Q: Is maternity coverage included?

A: Every plan offered in Georgia must cover complications of pregnancy and offer immediate coverage for newborns. Beyond these specific conditions, many plans do not coverage pregnancy unless specifically stated. Most plans can have maternity coverage added for additional cost.

Q: Do I have to take a physical exam to get health insurance?

A: It's up to the insurance company. Many plans just don't require exams or tests but do require a series of questions to be answered. Age and eligibility for preferred rates (lower cost rates) often need a physical exam within a certain time period.

Q: Do I need to see an agent to get health insurance?

A: It depends on the insurance company. One of the top reasons people get into serious debt is because of significant and unexpected medical expenses. You should ask your agent to help you understand what the maximum out-of-pocket costs would be for your particular coverage. This conversation is usually easier face-to-face.

Q: What questions should I ask my agent?

A: What is my monthly premium?

What is my deductible?

Is this a family deductible or a per person deductible?

What is my maximum out-of-pocket?

What is the Lifetime Maximum Coverage?

Is prescription coverage included?

What are my co-payments - if any?

What are my options for reducing the cost of coverage?

Q: Am I stuck with an annual contract?

A: No. It's like renting an apartment month-to-month. As long as you pay the premium you have coverage. If your situation changes and you need to improve or downgrade your coverage your insurance agent will help you with choices.

Q: Does my insurance cover me when traveling?

A: This depends on your network of coverage within the United States. Most plans have emergency coverage for travel with in the US. If it's international travel many plans exclude coverage for international travelers. There are options for temporary travel insurance.

Q: What if I'm on prescription medication?

A: It depends what the medication is. Tell your insurance agent. Depending on the medication, it may reduce your choices but you should still be able to get coverage.

Q: Can I be canceled?

A: Generally no, unless false information was given on the application.

Q: Can I be singled out for a rate increase?

A: If you are an individual then there is currently no regulation by the State of Georgia Department of Insurance regarding rate increases. You can combat rate increases on individual policies by increasing your deductible, looking at another insurance company or adjusting your coverage. If you are an individual within a group of 50 people or less, then the State of Georgia, Department of Insurance does have regulatory review. An individual within a group cannot have a rate increase unless the whole group receives an increase. Similar to individual polices, you can combat rate increases by increasing your deductible, considering another insurance company or adjusting your coverage.

Q: What is a pre-existing condition and why does it matter?

A: A pre-existing condition is a condition that existed prior to applying to a new insurance company. It could be high blood pressure or hypothyroidism or heart attack or stroke. A pre-existing condition will affect your cost of coverage and possibly whether that condition will be covered or even excluded from coverage. Tell your insurance agent and you'll be directed to the appropriate company for coverage.

Q: What if I had a recent accident or illness?

A: Most insurance companies will accept applicants with previous accidents or illnesses as long as no additional treatment is needed.

Q: What makes up an HSA Plan?

A: The plan needs to be a qualified "high deductible health plan" (HDHP)

A qualified HDHP is a health plan that meets the following requirements:

Individual coverage

• Annual deductible: $1,000 Minimum
• Annual out-of-pocket expense limit: not more than $5,000.

Family coverage

• Annual deductible: $2,000 Minimum
• Annual out-of-pocket expense limit: not more than $10,000.

• These plans do not have co-pays for doctor visits or prescription drugs
• These plans can be "network" plans
• Some qualified plans may have a first-dollar benefit or low-deductible benefit for preventive care only.
• In the case of family coverage, a plan is only an HDHP if under the terms of the plan no amounts are payable until the aggregate family deductible is met

An insurance carrier or licensed insurance professional should verify that the plan in question is actually a qualified plan. Penalties exist for individuals that set-up the accounts without the appropriate insurance.

Q: Why should I use an insurance agent to get health insurance?

A: A Qualified agent will be able to explain how the four main cost effecting components - Coinsurance, Co-payments, Deductible and Out-of-pocket (OOP) maximum, will effect your coverage and costs. They'll help you select or change coverage based on your need at the time. And when it's time for renewal, they're your best source for explaining the cost increases that are so common these days. Engaging an insurance professional typically will not add any cost to your insurance premiums.

Q: What affects my cost of insurance the most?

A: Primarily your health. The best way to get low cost health insurance is with good health. Tobacco use, height/weight ratio, prescription drug use and past health issues all contribute to higher premiums.

Q: What are usual customary and reasonable charges?

A: Most Health plans have established usual customary and reasonable procedures for a particular accident or illness. These usual customary and reasonable procedures also have acceptable costs. If your Doctor performs tests the insurance company does not include in the usual customary and reasonable procedures, you will be charged for them. Similarly, if costs are above the usual customary and reasonable charges you may also be billed for the amount not covered by your insurance.

Q : The doctor charged $3,500.00 for a medical procedure and insurance company only paid $2,000.00 because they say this is the UCR amount. Can they do this and do I owe the difference?

A: Unfortunately, the answer is yes. Medical fees do not always follow "rational" patterns and medical providers are free to charge according to their own fee schedule. To ensure rate stability and uniformity of coverage, UCR fees are established and serve as the maximum allowable charge for all insureds.

Q : Is there anything I can do to reduce or eliminate the difference in the UCR allowed and the actual doctor charge?

A: You can appeal to the insurer to re-evaluate the UCR amount allowed. The insurer may be able to justify additional payments and may also contact the medical provider to reach a compromise fee.

Q : Can I buy a policy that does not pay according to UCR so that I will not have to pay the difference charged by the doctor and allowed by the insurer?

A: Managed care policies (HMO & PPO) pay according to a pre-determined fees schedule agreed upon between the insurer and the medical provider. Thus, the doctor's charge will be paid by the insurer except for the deductible, coinsurance or copay owed by the insured. (Answer from GA Department of Insurance FAQ www.gainsurance.org)

Q: Is an HSA the best health insurance for everyone?

A: No. While many people will benefit from setting up an HSA, individual insurance preferences, situations, location and plans you qualify for will determine if it is the right type of coverage. You will benefit the most from an HSA if you save money on premiums from other insurance alternatives, and you will systematically fund the savings account. A good starting point is to look at recent years medical spending, and calculate the total dollar amount that would have been spent on premiums and medical expenses under terms of the HSA qualified plan. Compare it to the actual amount spent in the same period for insurance premiums, co-pays and co-insurance.

Glossary

Coinsurance is the portion of covered medical expenses you and your insurance company share after you meet your deductible each calendar year. As your share of coinsurance increases, your premium typically decreases.

Co-payment   Often called a "copay," it's the flat dollar amount you pay for a specific
medical service. Copay plans typically cost more because you're paying for the convenience of knowing what you'll spend each time you visit the doctor or fill a prescription.

Deductible  The amount you're responsible for before any benefits will be paid for covered medical expenses. The higher your deductible, the lower your premium.

HSA - Health Savings Account

HDHP - high deductible health plan

Insurance - the transfer of risk from an individual to an insurance company

Network Providers   A group of providers who provide care at a predetermined lower rate. Staying in the network is an effective way for you to control your health insurance costs.

Out-of-pocket Maximum   The maximum amount you're responsible for each year. The higher your out-of-pocket maximum, the lower your premium. It is typically a combination of deductibles, coinsurance and copayments.

Other Links:

The HSA Insider: Politics, Regulations and Industry News www.hsainsider.com

Investment Real Estate - www.andyritan.com

Web Design - Jay Kapp - www.kappkoncepts.com

State of Georgia, Department of Insurance - ww.gainsurance.org