Health Insurance Michigan | individual and group insurance solutions » FAQ

Office Visit Copay: 20% after Deductible, should mean what to me?

Billy Bj Strawter Jr — Thu, 03 Jun 2010 23:21:42 +0000

Frequently Asked Questions

If you have a health insurance plan that states office visit copay: 20% after deductible, what is the cost of your office visit?

Great question. If your plan does not include office visits prior to the deductible, you are responsible for the full cost of the office visit. That is, until you satisfy the deductible.

Once you satisfy your deductible you would be responsible for 20% of the cost of the office visit.

Example:

You have satisfied your deductible
Doctors Office charges you $100 for an office visit
The insurance company would pay $80 dollars towards the office visit
You would be responsible for the remaining $20 dollars.

Michigan health care insurance that covers lap band?

Billy Bj Strawter Jr — Mon, 17 May 2010 12:16:11 +0000

Frequently Asked Questions

What health care insurance covers lap band or gastric bypass surgery? Depends. Health care insurance covering the lap band surgical procedure is determined on a person-by-person basis. Some policies only cover the procedure when/if medically necessary. It may be covered if you meet the national guidelines for the care of morbid obesity.

Insurance Companies that cover Lap Band

These are companies that are known to partially cover or completely cover LAP Band surgery. It does not guarantee that you will be covered. Insurance companies cover surgery on a case-by-case basis.

Cigna
Aetna
TriCare
Blue Cross (some states)
One Health
Tufts Health Plan
Medicaid
American Family Insurance
Humana
Great West
First Health
Anthem BCBS

Verify Insurance

To determine if you insurance policy covers bariatric ( lap band ) surgery, refer to the insurance policy packet you would have received after paying your first premium. For group coverage, it would have been provided by your employer. If you don’t have a copy, contact your human resources department or your insurance provider. They will be able to provide a copy for you.

Most likely there are two sections that describe limits and the extent of your coverage. Look for:

Covered Expenses or What is covered (or similar) – This lists all the healthcare benefits for which the insurance company will pay.

What is not covered” or “When the plan does not pay benefits”. - cost that may not be covered by your plan

Look for statements where the health insurance company excludes coverage for weith control, treatment for obesity, surgery for weith control, or exclude outright bariatric surgeries.

Look closely for statements such as “Surgery for the treatment of obesity is covered when deemed medically necessary”. If bariatric or lap band surgery is excluded except when medically necessary, then if you meet the carriers guidelines, you may qualify.

Related Posts:

Cost of Lap-Band in Michigan

Financing Lap Band Surgery

Are individuals underwritten with group insurance?

Billy Bj Strawter Jr — Sat, 15 May 2010 22:46:31 +0000

Frequently Asked Questions

Yes. Group insurance is medically underwritten. The entire gr0up, including the individual are reviewed by underwriting for group health insurance.

Let’s take a look at why one might ask this question. Most often we hear this due to a concern about being denied for coverage.

The good news for those concerned is this. Health Insurance companies in Michigan underwrite individuals to determine your rate. The amount you pay monthly for health insurance.

When small group plans are medically underwritten, employees are asked to provide health information about themselves and their covered family members when they apply for coverage. When determining rates, insurance companies use the medical information on these applications. Sometimes they will request additional information from an applicant’s physician or ask the applicants for clarification. If a company is unable to obtain information necessary to accurately determine the risk of a particular applicant, it will underwrite more conservatively, meaning that the assumption relative to the missing information will be negative rather than positive.

Example: A person has a history of diabetes but it is controlled with medication and he is not overweight. If the company is unable to determine if that individual smokes or if he has normal cholesterol, it will assume that the missing information is negative and rate accordingly.

In most states the amount a company can vary a group’s premium rates based on medical underwriting factors is limited to a certain percentage of the average small group insurance rate. This is known as a rating band requirement, and the specifics vary by state.

If you have a pre-existing condition, a new insurance company can review your medical records for the last six months only and apply an exclusion of that condition from coverage for varying times according to the type of group plan you have. If you have maintained coverage of your pre-existing condition, without a break of more than 63 days, you are entitled to creditable coverage.

Please contact us at 888.320.5388 to answer specific questions not addressed here. Or ask anonymously at http://www.formspring.me/michiganhealth

Make it a great day!

Billy

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$0 copay for office visit after deductible. how much is the office visit?

Billy Bj Strawter Jr — Fri, 14 May 2010 13:30:33 +0000

Frequently Asked Questions

If you have a $0 copay for office visits after your deductible, how much does your office visit cost? That depends.

At first glance, without knowing what your copay before the deductible, all indications would be that you would pay nothing for your office visit. Of course assuming you have satisfied your deductible.

If you haven’t hit your deductible and you aren’t sure what your copay is before the deductible, a quick way to figure that out would be to look at your health insurance card.

Here is an example:

A quick review of the left side of the card shows your office visit copay is $25. $35 for a specialist. It also lists your X-Ray, Lab, and prescription benefits. Your card may be different.

If you have questions please comment or feel free to ask us anonymously at http://www.formspring.me/michiganhealth

Make it a great day!

Billy

Section 125 Pre-Tax Plans

Billy Bj Strawter Jr — Tue, 13 Oct 2009 01:33:55 +0000

Section 125 Plans, also known as Cafeteria Plans, came about through Congress in 1978 and are named after their Internal Revenue Code. Such plans provide an employee benefit plan under which the employee makes an irrevocable decision to forego a portion of future income in exchange for receiving future benefits not subject to income tax at reception date. Essentially, Section 125 plans are created using pre-tax dollars, enabling the employee’s dollars to stretch farther. The employer deducts the cost of the employee’s future benefits from present income as a business expense.

These Plans Usually Provide Three Options:

Premium Conversion – employee contributes a proportionate share of the family health care costs with pre-tax dollars.
Medical Reimbursement Account – employee is able to use a Salary Reduction Plan to pay with dollars on a pre-tax basis for medical expenses not covered by insurance; a separate medical reimbursement account is established for each employee.
Dependent Care Reimbursement Account – employee is able to use a salary reduction plan to pay with dollars on a pre-tax basis for dependent care expenses.

Section 125 pre-tax plans offer an opportunity for employers to save on their health insurance costs. However, implementing and administering the plan can be challenging:

According to the IRS, 93% of all existing plans are out of compliance.
Fines can include disqualification of all tax savings to employer (approx. 7.65%) and employee (approx. 23%) going back 5 years.

What is HIPAA?

Billy Bj Strawter Jr — Thu, 27 Aug 2009 16:19:30 +0000

HIPAA stands for the Health Insurance Portability and Accountability Act of 1996. It is a federal law written with the intent to provide improved portability and continuity of health insurance coverage. (While the law applies to the health plans of most employers, certain non-federal governmental self-funded plans are allowed to opt out of most of the HIPAA provisions.)

In brief, the law:

Places limitations on the pre-existing medical condition exclusion clauses health plans can include in their contracts;
Guarantees enrollment to individuals if certain conditions are met, and stipulates they cannot be charged more for benefits offered by a health plan, regardless of health status;
Under certain circumstances requires health insurance companies to offer individual insurance on a guaranteed basis once an individual exhausts their COBRA coverage;
Provides new rights to employees, allowing them to enroll in the health coverage of their employer if they have lost other coverage, or if they acquire a new dependent; and
Provides credit to individuals for prior health coverage and requires health plans to furnish participants with Certificates of Creditable coverage.

HIPAA preserves the right of the individual states to regulate health insurance, including their authority to provide greater protections than those that HIPAA offers.

Note: HIPAA is particularly important in your decision whether or not to elect COBRA coverage because it may affect when other coverage would become available to you and the types of other coverage available to you, including the extent to which coverage can be restricted under a “pre-existing condition exclusion.”

For more information from the federal government on HIPAA, see the federal government’s website:

HIPAA Online

What qualifies one for a leave under FMLA?

Billy Bj Strawter Jr — Thu, 27 Aug 2009 16:16:14 +0000

You must be granted unpaid leave for any of the following reasons:

The birth of your child or to care for your child after birth (the leave must be completed within 12 months of the birth).
The placement of a child with you for adoption or foster care (the leave must be completed within 12 months of the placement).
To care for your spouse, son or daughter, or parent who has a serious health condition.
In the event of a serious health condition that makes you unable to perform your job.
For a qualifying exigency arising out of your spouse’s, son’s, daughter’s, or parent’s being on active duty in the Armed Forces or being called up for active duty in support of a contingency operation.
To care for a child, parent, or spouse who has suffered an injury or illness during military service that makes the servicemember unable to perform his or her duties (in this case, the usual 12-week FMLA period is extended to 26 weeks within a 12-month period). If you are the nearest blood relative, you may qualify for this FMLA leave even if the injured servicemember is not your child, parent, or spouse.

If you will be taking leave based on any of the above, you may be required to provide your employer with advance notice.

Family and Medical Leave Act of 1993

Billy Bj Strawter Jr — Thu, 27 Aug 2009 16:14:51 +0000

The federal Family and Medical Leave Act (FMLA) requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to “eligible” employees for certain family and medical reasons. Certain states may have similar leave laws; however, state laws are not discussed here. For more information on state mandated leaves, contact the Human Resources Department.

For a list of the reasons that enable you to take an FMLA leave, see:

What qualifies one for a leave under FMLA?

Most employers who employ 50 or more employees during 20 weeks or more of the current or preceding calendar year are required to provide FMLA benefits to their employees.

You are eligible under FMLA if you have worked for a covered employer for at least 12 months and you worked for that employer for at least 1,250 hours during the previous 12-month period.

Note: The right to return to your position or an equivalent position after an FMLA leave is subject to exceptions for certain “highly compensated” or “key” employees. These are salaried, eligible employees who are in the top 10% of highest-paid employees. To see if this affects you, check with the Human Resources Department.

Medical benefits are continued under an FMLA leave.

What is ERISA?

Billy Bj Strawter Jr — Thu, 27 Aug 2009 16:11:59 +0000

ERISA, the Employee Retirement Income Security Act of 1974, governs most employee benefit plans. It is administered by the U.S. Department of Labor. The law gives certain rights to employees and gives employers certain responsibilities to act on the behalf of employees.

Note: A complete list of employers or employee organizations sponsoring the plan may be obtained by a plan participant or beneficiary upon written request to the plan administrator. Also, a participant or beneficiary may request in writing to the plan administrator whether a particular employer is a sponsor, and if so, the employer’s address.

The Plan Sponsor reserves the right to amend or terminate any of the benefit plans. It also reserves the right to interpret the plan language, construe uncertain terms and/or determine eligibility for plan benefits.

How long may I keep COBRA coverage?

Billy Bj Strawter Jr — Thu, 27 Aug 2009 16:10:31 +0000

Depending on the circumstances, the coverage may be kept for up to 18, 29, 36 months (or potentially even for life for certain retirees of bankrupt companies) under federal law — state law may expand benefits in some cases.

The following chart shows the length of coverage under federal COBRA rules depending on whether the individual is the employee or spouse or child of the employee:

Employee / Former Employee:
QUALIFYING EVENT	DURATION OF COBRA COVERAGE
Reduction in Hours	18 months
Termination of Employment*	18 months
Bankruptcy of Former Employer (for Retiree)	For life (subject to decision of the Bankruptcy Court)
Disabled as determined by the Social Security Administration on or before 60 days after Qualifying Event Date***	Up to 29 months if still disabled

Spouse of Employee / Former Employee:
QUALIFYING EVENT	DURATION OF COBRA COVERAGE
Death of Spouse (i.e., the employee)	36 months.
Termination of Employment of Spouse (i.e., the employee)*	18 months.
Divorce or Legal Separation	36 months.
Spouse (i.e., the employee) Becomes Entitled to Medicare (if prior to experiencing a Qualifying Event that is the termination, or reduction in hours, of employment)	36 months from spouse’s date of Medicare entitlement or, if longer, 18 months from the spouse’s Qualifying Event date (29 months if there is a disability extension).
Spouse of Retiree of Bankrupt Former Employer	36 months beyond the life of the retiree (subject to decision of the Bankruptcy Court).
Second Qualifying Event**	36 months.
Disabled as determined by the Social Security Administration on or before 60 days after Qualifying Event Date***	Up to 29 months if still disabled

Dependent Child of Employee / Former Employee:
QUALIFYING EVENT	DURATION OF COBRA COVERAGE
Death of Parent (i.e., the employee)	36 months.
Termination of Employment of Parent (i.e., the employee) *	18 months.
Reduction in Hours of Employment of Parent (i.e., the employee)	36 months.
Parent (i.e., the employee) Becomes Entitled to Medicare (if prior to experiencing a Qualifying Event that is the termination, or reduction in hours, of employment)	36 months from parent’s date of Medicare entitlement or, if longer, 18 months from the parent’s Qualifying Event date (29 months if there is a disability extension).
Child of Retiree of Bankrupt Former Employer	36 months beyond the life of the retiree (subject to decision of the Bankruptcy Court).
Second Qualifying Event**	36 months.
Divorce or Legal Separation of Parents	36 months.
Dependent Child Ceases to be Eligible Under the Group Health Plan	36 months.
Disabled as determined by the Social Security Administration on or before 60 days after Qualifying Event Date***	Up to 29 months if still disabled.

* The law does not require that COBRA coverage be made available if an employee is terminated for “gross misconduct.”

** If a spouse of dependent child has already started 18 months of COBRA continuation coverage when an event that would allow 36 months occurs, the maximum duration will increase to 36 months. In no case may the total amount of continued coverage be more than 36 months. Medicare entitlement is not considered a second Qualifying Event unless it would serve as a first Qualifying Event (i.e., would result in loss of coverage under the group health plan), which is not common.

*** If a Qualified Beneficiary is eligible for the extension to 29 months due to disability, the other family members on COBRA are also eligible for the same extension. Please note that you must notify the plan administrator within 60 days of the determination of your disability status by the Social Security Administration.