Group health insurance is when a group of people are covered under one health insurance plan. This is most commonly seen with employer-sponsored health insurance; however, self-employed individuals can also make their own health insurance group for themselves and their dependents.
Function
Your health insurance group number identifies your group from other groups who are insured with the same insurance company. You can find this number on your insurance card.
Features
Everyone insured with a company will be part of the same group. So, if you have employer-sponsored health insurance, you and your co-workers and their families who are all under the same insurance plan will all be part of the same group.
Significance
If you file your own claims, you will need this number in order to do so. If your doctor files your claims for you, then his office will need your health insurance group number in order to do so.
Coinsurance is an insurance term that indicates the percentage of a covered service that you’re responsible for. For example, if your dental insurance plan says your coinsurance for a root canal is 20 percent, you’re expected to pay 20 percent of the cost of your root canal. Most types of insurance, including health, dental and vision, may have coinsurance for services, depending on the terms of your policy.
Coinsurance and Premiums
Your premium is the amount you pay each month to be covered by your insurance plan. Plans with lower out-of-pocket costs have higher premiums, and plans with higher out-of-pocket costs have lower premiums. If you’re looking at two health insurance plan options, for example, the less expensive plan may have 30 percent coinsurance for specialist visits, and the more expensive plan may have 20 percent.
Copays and Coinsurance
Most insurance plans, including car insurance, health insurance, dental insurance and vision insurance, have out-of-pocket costs. In addition to coinsurance, there may be a copay, which is a set cost for a specific type of health care service. For example, your plan may have a $15 copay for primary care doctor visits and a $30 copay for a visit to a specialist. The difference between a copay and coinsurance is that a copay is the same amount regardless of the cost of the service. For example, if your copay for a primary doctor visit is $10, the copay stays $10 whether the doctor charges $100 or $200. With coinsurance, you would pay a percentage, so if you had a 20 percent coinsurance on primary doctor visits, and the visit cost $100, you would pay $20. If the visit was $200, you would pay $40.
Deductibles and Coinsurance
The other type of out-of-pocket cost you may see is a deductible. Deductibles are the amount you’re expected to pay for covered services before the plan will start paying. If your plan has a $500 deductible, you are responsible for $500 of medical expenses that the plan covers before the plan will begin paying benefits. A higher deductible lowers your monthly premium. Deductibles are paid before you start paying coinsurance. If you’re hospitalized, for example, and your bill is $1000, and your plan has a $500 deductible with 20 percent coinsurance, your total out-of-pocket cost would be $600.
Coinsurance and Your Policy
If your insurance policy has coinsurance, you should also check what your plan’s out-of-pocket maximum is. This is the most you would have to pay out-of-pocket in a given year. Your coinsurance amount may vary depending on the type of service. With health, vision and dental insurance, there may be a provider network, and your coinsurance amount may change depending on whether the service is in-network or out-of-network. Generally, if your provider is in-network, your coinsurance will be lower than with an out-of-network provider.
In the American healthcare system, most patients do not self-pay medical bills directly to the provider, but instead have insurance of some sort, whether private or government. Providers will submit claim forms to the patient’s insurance company for reimbursement under most methodologies. There are various types of reimbursement schemes and retrospective payments refer to the traditional method of reimbursement to healthcare providers.
Retrospective Payment Method
The retrospective payment method is considered a fee-for service payment method. This methodology involves insurance companies and other third parties making payments after the provider has rendered a service, based on what the provider charges for the service rendered. Fees under this methodology are reimbursed based on each individual service rendered. The rationale behind the retrospective payment method is to give maximum freedom of choice in required services for the patient and the provider.
Why Retrospective Payments
Retrospective payments keep the choice of medical treatments and service in the hands of qualified healthcare professionals, aligned with the comfort level of the patient. Rather than having unqualified professional in finance companies decide on the treatment plan for a patient, based on economic assumptions, healthcare professionals and patients can put healthcare concerns first. Yet, no system is perfect and inefficiencies can result.
Retrospective Payments and Medicare
In 1965, Congress established Medicare and adopted the retrospective payment method, traditionally used in the private sector. The rationale seemed in-line with keeping America healthy, particular the elderly for whom the Medicare plan was intended. Medicare took this a step further, and defined a payment method where the government made interim payments to providers throughout the year and providers reconciled those payments with allowable costs, as defined by regulations are the year’s end. This lead to ever-escalating Medicare costs over a period of 18 years, increasing to almost $37 billion annually by 1983. Consequently, Medicare abandoned the retrospective payment method.
Problems Noted With Retrospective Payments
Controversially, retrospective payments have come under fire for bloated expenditures, despite offering incentives to provide quality healthcare. The main issue — as illustrated with the Medicare problem — is cost containment and adequate control of healthcare resources. For example, a hospital under this system might maximize patient stays in the hospital, because this theoretically equates to more payments. This wastes resources on patients that don’t really need the resources, thus putting strain on the healthcare system, while driving up costs for the individual patient and his third-party payment provider.
Medigap is insurance against medical expenses that are not covered by original Medicare. What you pay for a Medigap policy depends on the coverage, your general health and especially where you live. You will likely pay $21 to $44 a month for the least expensive plan.
Essentials of Medigap
In 47 states, Medigap insurance comes in standard benefit packages lettered A through N. Massachusetts, Minnesota and Wisconsin have their own standardized plans. The basic plan is Medigap A. It covers a year of hospital care beyond Medicare benefits, hospice costs and blood that Medicare doesn’t pay for. It also covers your 20 percent share of medical expenses under original Medicare.
Medigap insurers must offer A and either C or F. The C and F plans cover a gamut of out-of-pocket expenses. They’re identical except that F covers excess charges beyond Medicare Part B benefit caps, and C does not.
Typical Low and High Premiums
High- and low-deductible F plans account for the lowest, and sometimes the highest, premiums, but C plans ranged at least as high. For the first enrollment period at age 65, the lowest monthly premiums run from $21 to $32 in zip codes located in Modesto, California; Houston; Portland, Oregon; Jackson Hole, Wyoming; and Detroit. In Seattle and Old Greenwich, Connecticut, the lowest were $44 and $50, respectively. On the high end, monthly premiums ran from $244 in Jackson Hole to $467 in Detroit, while Old Greenwich’s costliest policy was $700 per month. In short, location matters.
Average out of Pocket
Medicare’s estimates of total out-of-pocket costs, offered for each plan type in each location, tell an interesting tale. For a 65-year-old, high and low costs differ by just $13 a month in Portland (median income $52,657), the low being $523 a month for an A plan, but by $65 in Houston ($22,525), with a low of $523 for a G plan. The difference is $54 a month in Seattle (median income $65,277), where the low is $542 a month for a K plan, and $55 in Detroit ($26,325), where the low is $537 for a high-deductible F plan.
The Cheapest Choice
To find your best plan, go to Medicare’s information website, Medicare.gov. Under the "Supplements & Other Insurance" tab is "Find a Plan." Put in your zip code, and you’ll get a chart of benefits and premiums for every type of policy you can buy. Your cheapest Medigap option is a fixed-premium, "issue-age-related" plan chosen when you first sign up for Medicare. If you don’t sign up then, insurers can charge more, limit your plan options or turn you down altogether. The official "Choosing a Medigap Policy" booklet explains this and more, including how to switch plans.
Saving Money
You can save money by choosing a plan that offers only what you need. Foreign travel emergency coverage is useless if you only travel stateside, for example. If you have modest means and a chronic illness, you may want coverage for excess costs — costs that exceed Medicare’s Part B benefits cap. Ordinarily, that would come out of your own wallet. But then, the highest out-of-pocket expenses occur with repeated hospitalizations, according to a 2014 Kaiser Family Foundation study. Low-premium plans that protect you from catastrophic expenses may be just the ticket. Ultimately, it’s your call.
Insurance for health, home and cars is essential to make sure you are protected; however, having your health insurance cover all of your medical needs is often a struggle. When diving into the world of what is seen as cosmetic or elective surgeries, it becomes even more of a struggle to have the procedures covered. Tubal reversals are usually seen as an elective procedure, and will result in most insurance companies denying coverage.
Tubal Reversal
Many women choose to have a tubal ligation, which severs the fallopian tube and prohibits an egg from entering the uterus, fertilizing and implanting. As time passes, however, some women decide they would like to have a baby and wish to reverse the ligation and restore function to the fallopian tube. The success rate of the process varies widely by the surgeon and type of ligation that was originally performed.
Elective Procedure
Insurance companies often view the tubal reversal as elective. Health insurance is designed to fix health issues, and someone choosing to have a tubal reversal is seen as not a health issue, but rather a desire. It is viewed very similarly to cosmetic surgery. It is very difficult to find any insurance company that will cover any elective procedure, including tubal reversal.
Insurance
Call your insurance company or prospective insurance companies. Any billing to an insurance company must include procedure codes and diagnosis codes, and use these two specific codes when inquiring about coverage for tubal reversals: ICD 628.2 and CPT 58750. These codes rarely change, but you can call your doctor to verify that these are the codes he will use in billing. If the insurance provider states they will not cover the procedure, ask if any portion of the surgery can be covered, such as anesthesia.
Medical Necessity
In some cases, a tubal ligation can result in medical issues. If your doctor feels that your tubal ligation should be completed for your health, he can write a letter to the insurance companies and make the case for medical necessity. When a procedure is requested out of medical necessity, the chances for insurance approval rise.
The laws of each state govern workers’ compensation settlements. If you are currently a work comp claimant, you have a right to settle the case with the insurance company handling the claim. Settlement is optional for both parties; the law will not force you or the insurance company to negotiate a settlement. If you do reach an agreement, the time frame for your final payment is generally a subject of the agreement.
Settlement Terms
A settlement releases the insurance company for any further liability for the claim. Indemnity benefits will stop, as will medical benefits (unless you can negotiate to keep the medical benefits continuing). Your attorney will negotiate a lump-sum payment, which usually represents a discount on the stream of future benefits that the insurance company will no longer have to pay.
Terms of Payment
Some states require that insurance companies make the lump-sum payments within a time limit, in most cases 30 days. Your attorney will also be able to negotiate this deadline and will have a standard length of time written into his settlement agreement template. Fifteen or 30 days is the most common range of time for a lump-sum payment on a workers’-comp settlement. All parties have an interest in keeping to the deadline. The insurance company would like to close the case and end all future liability; the attorney wants to collect his fee, which is usually a percentage of the settlement; and you have an interest in a rapid lump-sum payment so you can get on with your life and put your workers’ comp experience behind you.
Court Settlements
Workers’ comp settlements are usually accomplished outside of the judicial process; there are no hearings or litigation necessary. The parties must, however, submit the agreement for the approval of a workers’ compensation court or the state’s public workers’ comp agency, which will render its decision and establish an effective date for the settlement. If a court sets the terms of an agreement, it will also set the deadline for any payments.
Failure to Pay
Insurance companies have a procedure in place for payment of settlements, which includes the deduction of attorney fees, accounting paperwork and the process for issuing and mailing out checks. In addition, the carrier may require Medicare approval or another contingency that will affect the delivery of your settlement money. If you do not receive payment within the agreed-upon deadline, you may file for a hearing in civil court to enforce the settlement. This rarely happens, because insurance companies don’t want to face further legal costs or, in some states, lose their license to sell insurance altogether for non-payment of a settlement.
When babies are born prematurely, have difficult births or have serious health issues, they sometimes are admitted to the neonatal intensive care unit, or NICU. This special hospital department features high-security measures and unique equipment and tools designed for infants. While most parents have enough to worry about if their babies are sick, they can be inundated by expensive bills from the experience.
Average Daily Cost
The overall cost for a baby’s stay in the NICU is typically determined by his length of stay there. Each baby spends different amounts of time in the NICU, depending on the reasons for being there in the first place. For example, premature babies born before week 37 often spend a month or more in the NICU, simply because vital organs, such as lungs, are not fully developed and they need to be on ventilators full-time. According to a 2010 article in “Managed Care Magazine,” the average cost for infants in NICU is around $3,000 per day. This average does not include surgeries or helicopter transports.
Average Length of Stay
Around 30 to 35 percent of NICU babies are in these special units for fewer than four days. Some of the most common reasons for these stays are difficult labors that caused some type of serious temporary health concern, such as swallowing the meconium during birth. These stays typically cost between $12,000 and $20,000 depending on the severity of the health issue and number of days in the NICU. It’s the babies that are born very prematurely that usually rack up the most expensive bills. According to “Managed Care,” 65 to 70 percent of NICU infants stay in the special unit for an average of 20 days. These stays cost between $40,000 and $80,000 with a commercial health insurance plan. According to a 2008 article in “Bloomberg Businessweek,” a premature infant born in week 28 had a NICU stay for two months that cost $400,000, not including surgeries.
Other Cost Factors
The level of needed care contributes to the high cost of NICU stays. For example, most NICU babies need the assistance of many life-saving tools and equipment. Incubators that keep babies warm and ventilators are very common in the NICU. Babies are generally hooked up to around-the-clock monitors that measure blood pressure, heartbeat rates and blood-oxygen rates. They also must have IVs that give them necessary medications, as well as nutritional needs, as most cannot breastfeed or take a bottle normally.
Health Insurance Coverage
The cost of an expensive NICU stay is typically covered by health insurance plans. NICU stays four days or less are often partially covered under the maternal insurance. Most people meet their annual deductibles quickly with NICU stays and only have to pay what their deductible cap is. Parents who do not have health insurance may be able to get NICU costs covered by Medicaid.
Many health insurance plans feature deductibles. A deductible is a dollar amount that you must pay before the health insurance company begins paying, minus copayments. Deductibles are usually features of Preferred Provider Organizations and may range greatly in dollar amount. Group health insurance, obtained through an employer or association, decides the deductible amount and the date the deductible will reset. Typically, deductibles reset on an annual basis.
Calendar Year
If your group health insurance runs on a calendar year, the benefit plan is effective on January 1 and ends on December 31. Per the terms of the group health contract, the plan will start new each January 1. If the plan design features annual deductibles, the deductible will reset each January 1. Any plan limitations that are annual, such as number of doctor visits, therapy sessions or hospital days, may also reset each January 1.
Benefit Year
Group health insurance plans may contract on a benefit year, not a calendar year. Depending on when your employer or association contracts with the insurance company, the benefit year may start at any specific date. The contract date is the effective date and is often the first of a particular month. Many group insurance plans begin on July 1, although it may be the first of any month. The deductible will reset on the first day of the benefit year. If the plan runs on a benefit year of July 1 to June 30, the annual deductible will reset each July 1.
Individual Plans
If you do not participate in a group health insurance plan but have individual, or private, health insurance, the deductible reset date depends on your plan design. If you choose a plan with a deductible, the deductible will reset each year. If your plan runs month-to-month, the insurer will renew your plan each month and maintain your deductible with a reset at the 13-month mark. For example, if you select a plan with a start date of July 15, you must pay toward the deductible until July 14 of the next year. If you are still covered under the same plan, your deductible will reset on July 15.
Deductible Amounts
Deductibles vary from none to several thousand dollars. The amount of the deductible plays a large role in the premium amount, the amount of the actual policy. The larger the deductible amount, the less expensive the policy. Health Maintenance Organizations do not feature deductibles. With group health insurance, the deductible amount is always factored into the underwriting of the policy. Your employer will decide the deductible amount for employees along with the date the deductible will reset.
Most health insurance plans require patients to pay a copay for services. For example, the patient must pay $10 upfront for a doctor’s visit and the insurance company pays the rest of the bill. In addition, patients may have to pay out-of-pocket all costs up to their deductible on their insurance policy. Some kindhearted health care providers waive co-pays and deductibles for patients who cannot afford them. However, if a physician does this routinely, he may fall afoul of federal and state insurance fraud laws.
Routine Waiving
In most states, it is illegal to routinely waive copays and deductibles for patients. Health care providers who do this may be charged with the crime of health insurance fraud because they are claiming the wrong amount for services when they make insurance claims. For example, if a patient has a 10 percent co-pay, the insurance company pays $90 on a $100 bill. But if the health care provider waives the copay, the patient’s bill is only $90 total, not $100.
Financial Hardship
If a patient suffers financial hardship, physicians may choose not to collect debts from them without risking allegations of insurance fraud. For example, if the physician does not charge a copay to a patient during a period of severe hardship, the physician can choose not to pursue collection activity against the patient for the copay he owes. However, physicians cannot routinely forgive debt; they must reserve this only for patients who are suffering a financial crisis or emergency.
Public Insurance
The same laws apply to Medicare and Medicaid patients as to patients with private insurance, and the risk is greater if a physician does not comply with these laws, as the physician may be charged with fraud against a government agency. In addition, physicians must apply hardship programs to all patients — they cannot forgive copay debt or waive copays for patients with public health insurance during times of crisis but require patients with private insurance to pay full copays regardless of their financial circumstances.
What to Do
If a physician has a good reason for waiving a copay or failing to pursue debt collection against a patient, she should keep records of her conversations with the patient regarding this issue as evidence that she made a good faith effort to comply with the law and made exceptions only for specific reasons. In addition, health care providers should keep track of all payments and note any payment where the copay was waived as evidence that they do not waive copayments routinely.
Delta Dental is an insurance company that has been providing dental coverage to Americans since 1954. While Delta Dental Plans Association is a nonprofit organization, it partners with 39 for-profit affiliates nationwide. It is the largest dental benefits carrier in the United States and offers a variety of health plans for the people it covers. However, like any service, you can terminate Delta Dental as your carrier if it no longer meets your needs.
Contact a Delta Dental representative. Look at the back of your Delta Dental insurance card for a telephone number to reach him.
Tell the representative you would like to cancel your policy. You will be required to notify Delta Dental in writing. The representative will tell you where to send the cancellation letter or email.
Write a simple request stating that you would like to cancel your policy with Delta Dental. Send it to the email or address given you by the insurance company representative.
Wait for confirmation of cancellation. Cancellation refunds will vary from plan to plan. Some branches of Delta Dental will offer you a full refund if you cancel within 30 days of initial enrollment. The time of termination also depends on when you mail your letter. For example, Delta Dental of Colorado will terminate your contract at the end of the month if it receives notice by the 20th.
The Arizona Health Care Cost Containment System (AHCCCS) provides free or low-cost health care to low-income residents of the state. This health program represents the state’s Medicaid program, funded by state and federal money. Each April 1, the state adjusts the income eligibility levels for AHCCCS, which vary according to several factors.
Eligibility
AHCCCS offers health insurance for families with children who are under 19 years old and who meet income and eligibility requirements. For those who qualify, there are no monthly premiums. Applicants must be Arizona residents as well as U.S. citizens or qualified immigrants. In addition, applicants who qualify for unemployment or Social Security benefits must apply for them.
Income Limits by Family Size
In 2011, for a family of five, the monthly income limit is $2,150, before taxes. For a family of four, the limit is $1,838. For a family of three, the limit is $1,526. For a family of two, the limit is $1,215. For a family of one, the limit is $903. For larger families, the income limit is $2,150 for the first five members and $311 for each additional member.
Unearned and In-Kind Income
The program counts unearned as well as earned income. Unearned income includes benefits such as unemployment, Social Security disability, Supplemental Security Income, pensions and all other kinds of income that do not come directly from wages. The AHCCCS also counts in-kind payments when figuring income. In-kind payments include food, shelter and other items that can be converted to cash.
Children’s Income
The program has various rules about counting income from children, depending on their age, marital status, living arrangements, and status as a dependent of an eligible adult. The easiest method to calculate the income guidelines for household members is to use the matrices included in the AHCCCS Eligibility Policy Manual, available online.
KidsCare
A low-premium health insurance program known as KidsCare is available to families who exceed the income limits. Some children qualify for AHCCCS insurance if they are under the age of 21 and, as of their 18th birthday, were in the state’s foster care program.
CPT and ICD-9 are coding systems used in the medical billing process. CPT, or Current Procedural Terminology, is used to report office visits and procedures to insurance companies for reimbursement of services. The ICD-9, or International Classification of Diseases, 9th Revision, assigns codes for patient diagnosis purposes. The codes in the ICD-9 code book must be submitted on the insurance claim form to show medical necessity for the office visit or procedures that were performed on the patient.
Things You’ll Need
CPT Code book
ICD-9 Code book
Patient encounter form or medical record
Read the patient’s medical encounter form or medical record to familiarize yourself with the most recent visit.
Identify the physician’s diagnosis or reason for the patient’s visit. If you are looking at the patient’s encounter form, there should be a space for the diagnosis to be listed. If no diagnosis can be assigned at the end of the visit, note signs and symptoms as reasons for the visit to be entered in the place of a diagnosis.
Identify any medical procedures or services that were performed. This can be found on the encounter form as well.
Use the ICD-9 code book to look up any diagnosis codes. More than one may be listed. First look up the name of the diagnosis in the alphabetical section of the ICD-9 code book. Then double check the code referenced by looking up that number code in the tabular section located in Volume 1 of the ICD-9 code book. If you are coding from a patient encounter form, there may be only number codes listed for diagnoses. Look up these numeric codes in the tabular section as before to ensure that the diagnosis code matches the correct physician diagnosis.
Look up any procedures, drugs or other medical services provided to the patient in the CPT code book. The patient will be assigned a code for the type of physician encounter (office visit, ER visit, outpatient surgery, etc.) and also codes for procedures or other services performed. Use the CPT codes just as you would the ICD-9 code book. First look up the procedure or service in the alphabetical index, then go to the numeric section and find the proper procedure. Read all notes carefully in the CPT book to make sure the code you assign exactly matches the one performed. These codes may also be listed on the patient encounter form. If so, look up these codes in the numeric section to ensure they are the same as the procedures performed on the patient.
