Insurance Coverage: Knowing What You Have and How to Keep It

1. Insurance Coverage:Knowing What You Have and How to Keep It Sally McCarty Orlando, Florida June , 2008

2. Know Your Health Plan • Traditional Indemnity? • PPO? • HMO? • Employer Group? • Small Employer Group? • Individual? • Other Type of Coverage?

3. Traditional Indemnity Plans • Reimburse enrollees for covered expenses incurred due to sickness or injury. • Expenses are reimbursed after: • coinsurance (percentage share of cost for which the enrollee is responsible) and • deductible (annual amount of out-of-pocket that must be paid by enrollee before benefits begin) amounts are met.

4. Preferred Provider Organization • Payment mechanism is the same as traditional indemnity. • Expenses are reimbursed after coinsurance and deductible amounts are met. • Coinsurance is higher when services are provided outside of plan’s provider network. • No referral process is required.

5. HMO • Enrollees must choose a physician as their primary care physician (PCP). • Founded on the premise that covering preventive care while controlling costs will result in better health care and lower rates of health care inflation. • PCP is the "Gatekeeper" for all medical services.

6. Employer Group • Subject to HIPAA protections • Limits to pre-existing condition exclusions • Non-discrimination provisions apply • More… • If more than 20 employees, subject to COBRA • If Small Employer Group, subject to HIPAA Guaranteed Issue

7. Non-Discrimination Provisions Under HIPAA, you can’t be charged more or removed from a group plan due to: • Health status • Genetic information • Claims experience • Receipt of health care • Medical history • Evidence of insurability • Disability • Medical condition -physical & mental illness

8. Individual (Non-Group) Coverage • Coverage that is sold by health insurance issuers or HMOs to individuals/families who are not part of a group health plan. • Might be provided through an association or other group, such as college students or self-employed individuals. • Only HIPAA Protection is guaranteed renewability.

9. Options When Losing Coverage • COBRA • Florida Small Group Conversion Policy • Trade Adjustment Assistance • HIPAA Eligible – guaranteed issue of an individual policy or a group conversion policy • Self-employed (one-life groups) open enrollment

10. COBRA • Are you eligible for COBRA? • Your employer has 20 or more employees • Employment terminates for other than gross misconduct • 102% of Total Premium (Employer + Employee share) • 18 months of coverage – up to 36 in some circumstances • Qualifying event: • Spouse of employee who becomes eligible for Medicare • Divorce or legal separation from covered spouse • Death of covered spouse • Loss of dependent child status under plan rules • 60 Days to Sign Up

11. Florida Small Group Conversion • If your employer has fewer than 20 employees • By Florida law, you have a right to pay for continuation coverage for 18 months.

12. Trade Adjustment Assistance • A federal law called the Trade Adjustment Assistance Reform Act may pay 65% of the cost of your health insurance for up to 3 years: • If you recently lost your job because of imports or jobs moving overseas, • If you are a retiree aged 55 or older, your former employer no longer provides your pension, and your pension benefit is paid by the federal Pension Benefits Guaranty Corporation,

13. HIPAA Federally Eligible • At least 18 months of continuous creditable coverage. • Most recent coverage under a group plan. • Not eligible for another group health plan. • Most recent coverage not cancelled due to nonpayment of premiums or fraud. • Not eligible for Medicare or Medicaid. • COBRA or state continuation coverage exhausted. • Did not accept a conversion or short-term limited duration policy.

14. Florida HIPAA Eligibles • Leaving a Group Plan • Employer required to offer a conversion plan • Premium can be up to 200% of standard risk • Benefits determined by Florida regulation • Carriers in the individual (non-group) health insurance market must guarantee issue their two most popular currently marketed plans to HIPAA-qualified persons leaving a self-funded plan.

15. Self-employed Guarantee Issue • Florida requires its small group carriers (e.g., carriers selling health insurance in the small group market) to: • Offer insurance on a guaranteed issue basis each August to self-employed individuals (one-life groups) • The carriers can charge up to 150% of their standard rate for these individuals.

16. ASSESS YOUR NEEDS • Which benefits are the most essential for you or your family? • Does the plan provide access and adequate coverage for the specialists and the specific treatments you and your family need? • Will the location of the plan’s network doctors make transportation an issue?

17. How is Factor Covered? • Is Factor coverage a medical or pharmacy benefit? • If a pharmacy benefit, are there separate annual benefit caps for pharmacy? • If a pharmacy benefit, are there separate benefit limits, out-of-pocket maximums, or copayments for factor? • If a medical benefit, are there separate benefit limits, out-of-pocket maximums, or copayments for specialty injectables? • Under either option, what are the coinsurance percentages or co-payments for clotting factor?

18. Insurance Needs for Families Dealing with a Bleeding Disorder • INCREASE OR ELIMINATE LIFETIME CAPS.The average $1 million lifetime cap established by the insurance industry in 1970 would equal $18 million today if indexed for inflation • ASSURE THAT OUT-OF-POCKET MAXIMUMS (OOPs) APPLY TO SPECIALTY INJECTABLES. 20% coinsurance with no OOP will certainly drain an average family’s savings without a limit on OOPs for that category

19. Insurance Needs, continued • Access to: • Medically prescribed and cost efficient health care • Exact brand and quantity of clotting factor prescribed by physician • Other necessary ancillary services necessary for optimum care • Providers who follow minimum standards of care in handling and delivery of factor and other health care services

20. Be Alert For: • Insurers cutting costs by: • Tiered Drug Plans • Separate Out-of-Pocket Maximums or Annual Caps for Specialty Injectables • Additional restrictions on provider networks, especially pharmacy/home health providers • Many other “creative” means to cut costs are being employed – especially by ERISA plans

21. Need Help? Health Plans: • Florida Office of Insurance Regulation • Toll Free:1.800.342.2762 • Web Site: www.floir.com. Self-funded ERISA plans: www.dol.gov/ebsa • Click on one of the following: • Compliance Assistance • Consumer Information • FAQs • Contact Us

22. Need Help? • U.S. Department of Labor’s “Frequently Asked Questions about COBRA Continuation Coverage” • Web site:www.dol.gov/ebsa/faqs/faq_consumer_cobra.html • Toll free 1.866.275.7922

23. Need Help? • Trade Adjustment Assistance Act • Health Coverage Tax Credit (HCTC) Customer Contact Center: • Toll-free 1.866.628.HCTC • Web site: www.irs.gov/pub/irs-utl/hctc_program_kit_07-05.pdf.