The Employee’s Guide to Health Plans

Definition
Primary Care Physician (PCP)
Network of Providers
Referrals
Deductibles, Coinsurance, Copayments, Claim Forms
Fee-for-Service (FFS)
Reimburses health care providers for services. Tends to be the most costly for employers. Not required; employees can choose any provider. No network; can choose any provider. Not required Deductibles & coinsurance may be required. Claim forms may be used.
Health Maintenance Organization (HMO)
Covers services performed by providers in a network & tends to be a low-cost,  restrictive system. Required; the PCP coordinates all medical care and must make referrals to specialty providers for employees. Services by out-of-network providers are not typically covered under the plan. Required; PCP coordinates all medical care May require employee cost-sharing through deductibles, co-pays or coinsurance.
Preferred Provider Organization (PPO)
A network of providers & allows the use of providers outside of the plan’s network, more flexible than an HMO, but more expensive. Not typically required. Some PPO vendors offer incentives for employees to visit a PCP to coordinate medical care. Network & the plan allows for use of out-of-network providers with greater cost-sharing by employees. May not be required Coinsurance, deductibles & co-pays are the standard; usually, lower when using in-network providers.
High Deductible Health Plan (HDHP)
Usually paired with a tax-advantaged account to pay for medical expenses. Common options are HRAs & HSAs savings accounts. Not required but there are incentives for using providers that are reasonably priced. Not required but are offered to bring savings to employers & employees. Not required Typically low or no coinsurance after the deductible is met. Deductibles are substantially higher than other plans.
Health Savings Account (HSA)
A tax-advantaged account used to pay for qualified medical expenses. An HSA must be used with an HDHP. Funds remaining in the account at the end of the year are rolled over. Not Required. May be used to pay for qualified medical expense. Not Required. May be used to pay for qualified medical expense. Not required, may be used to pay for any qualified medical expense. N/A
Point-of-Service Plan (POS)
Combines elements of an HMO & PPO. When employees need health care, they can choose how it will be received. If an employee initially sees a PCP & stays in-network, then more substantial benefits will be received versus not seeing a PCP first. Required when accessing HMO-like benefits of the plan. Not required when accessing PPO-like benefits of the plan. Employees must stay in-network Required for the HMO portion of the plan; not required for the PPO portion. No deductibles; minimal coinsurance or co-pays for HMO portion. Deductibles, coinsurance & co-pays are typical for the PPO portion—lower for in-network providers.
Health Reimbursement Arrangement (HRA)
Allows employers to set aside an amount of funds to reimburse participating employees for medical expenses & often combined with another health plan. May not be required. Subject to the paired health plan and employer. May not be required. Subject to the paired health plan & employer. May not be required. Subject to the paired health plan & employer. N/A
Health Flex Spending Account (Health FSA)
Allows employees to contribute funds that are not subject to payroll tax. Any unused funds are lost after a grace period. Employers have the option of allowing employees to carry over up to $500 of unused funds from one year to the next. May not be required. Subject to the paired health plan. May not be required. Subject to the paired health plan. May not be required. Subject to the paired health plan. N/A

Answers to the Most Frequently Asked Benefit Questions

Confused about common health insurance benefits terms? Here are answers to the most Frequently asked benefits questions.

What is a Deductible?

A deductible is the amount of money you or your dependents must pay toward a health claim before your organization’s health plan makes any payments for health care services rendered. For example, a plan participant with a $100 deductible would be required to pay the first $100, in total, of any claims during a plan year.

What is Coinsurance?

On top of your deductible, coinsurance is a provision in your health plan that shows what percentage of a medical bill you pay and the percentage a health plan pays.

What is an Out-of-pocket Maximum (OOPM)?

An OOPM is the maximum amount (deductible and coinsurance) that you will have to pay for covered expenses under a plan. Once the OOPM is reached the plan will cover eligible expenses at 100 percent.

What is an Explanation of Benefits (EOB)?

An EOB is a description your insurance carrier sends to you explaining the health care benefits that you received and the services for which your health care provider has requested payment.

What is a Preferred Provider Organization (PPO)?

A PPO is a group of hospitals and physicians that contract on a fee-for-service basis with insurance companies to provide comprehensive medical service. If you have a PPO, your out-of-pocket costs may be lower than in a non-PPO plan.

What is Utilization Management (UM)?

Utilization Management is the process of reviewing the appropriateness and the quality of care provided to patients. UM may occur before (pre-certification), during (concurrent) or after (retrospective) medical services are rendered.

For example, your health plan may require you to seek prior authorization from your UM company before admitting you to a hospital for nonemergency care. This would be an example of pre-certification. Your medical care provider and a medical professional at the UM company will discuss what is the best course of treatment for you before care is delivered. UM can reduce unnecessary hospitalizations, treatment and costs.

What is a High Deductible Health Plan (HDHP)?

An HDHP is a type of insurance plan that offers a low premium offset by a high deductible. Because of the low cost of the plan, the insurer will not cover most medical expenses until the deductible is met. As an exception, preventive care services are typically covered before the deductible is met. HDHPs are often designed to be compatible with heath savings accounts (HSAs), which are tax-advantaged accounts that can be used to pay for qualified out-of-pocket medical expenses before the HDHP’s deductible is met.

Be a Wise Health Care Consumer

How to Choose the Right Doctor

Choosing a doctor is a significant decision. Primary care doctors, specifically, provide you medical care over a long period, helping you stay healthy, manage your care and recommend specialists when needed.

Different types of doctors will meet different needs:

  • Internists and family practitioners are the largest group of primary care physicians for adults
  • Women may see OB/GYN for some of their medical care needs
  • Pediatricians and family practitioners are the primary caregivers for many children

The following guideline will help you find the best physician to meet your needs.

Review your health plan and any restrictions it has on the providers you can see—most plans have provider directories that list the doctors available to you. Make sure you know whether or not you are covered if you see a physician that is outside of the network.

For each doctor that is available to you, find out:

  • If the doctor is highly rated by a consumer or other group
  • If the doctor has experience with your condition(s)
  • If the doctor has privileges at the hospital of your choice
  • If the doctor is part of your health plan’s network
  • If the doctor is conveniently located
  • The doctor’s office hours, including evening and weekend availability
  • The doctor’s cancellation policy and whether or not reminders are provided
  • If the doctor provides urgent or emergency care
  • If advice is available via telephone
  • Anything else that is important for you, personally

If you still haven’t made a decision, you can try:

  • Asking doctors, friends, co-workers or relatives for a referral
  • Calling the American Medical Association at 312-464-5000 for information on specific physicians’ training, specialties and board certification
  • Arranging an appointment or meeting with the doctors you are most interested in—if you are not comfortable around him or her, you will likely not be happy with the care you receive

Making sure that your doctor is someone that you trust is very important—take your time selecting a health care provider that truly meets your needs.

Easy Halloween Safety Tips

During all the fun of Halloween, it is important to remember that this holiday requires some extra safety precautions. Most Halloween-related injuries can be prevented if parents supervise their children’s activities.

Costume Safety

Tips to help you select a safe costume for your child:

  • Think safety when selecting your child’s costume; avoid long, baggy or loose-fitting costumes and shoes that may be difficult to walk in.
  • Choose costumes, wigs and accessories made from fire-retardant materials.
  • Select costume colors and materials that are highly visible to motorists.
  • Opt for facial makeup instead of a mask that may limit a child’s vision or breathing.
  • Buy makeup labeled “FDA-approved” or “non-toxic,” and remove makeup promptly to avoid allergies or adverse reactions.
  • Make sure costume accessories, such as swords or magic wands, are made of flexible materials.
  • Add strips of reflective tape to costumes and trick-or-treat bags to make children more visible.

Pumpkin Carving Safety

To avoid injuries while carving pumpkins:

  • Carve pumpkins on a flat surface with good lighting.
  • Consider using a pumpkin-carving kit that includes special, easy-to-use cutting tools.
  • Have children ages 5 and younger draw on the pumpkin’s face—then you do the carving.
  • Light pumpkins using votive-style candles.
  • Place lighted pumpkins away from flammable objects, such as curtains.
  • Never leave lit pumpkins unattended.

Trick-or-treating Safety

Parents should be aware of the risks when trick-or-treating:

  • Remind children to walk only on sidewalks, and to look both left and right before crossing at corners or crosswalks.
  • Never let a child enter a home to receive candy or a treat unless accompanied by a parent.
  • Instruct your child to visit only well-lit houses.
  • Never allow children under the age of 12 to trick or treat alone. Older children should plan their routes ahead of time so their parents know where they are.
  • Instruct children to never approach a car, or accept treats from a person in a car.
  • Remind children to stay alert for house pets and strangers.
  • Inspect your children’s candy before they eat it. Wrapped treats are the safest. Dispose of fresh fruit, unwrapped or homemade treats, or anything that looks remotely suspicious.
  • Check for choking hazards, such as hard candy, gum, peanuts or small toys, before letting a small child eat his or her treats.

Court Orders EEOC to Reconsider Wellness Rules

The U.S. District Court for the District of Columbia has directed the Equal Employment Opportunity Commission (EEOC) to reconsider its final wellness rules under the Americans with Disabilities Act (ADA) and the Genetic Information Nondiscrimination Act (GINA).

The final rules allow employers to offer wellness incentives of up to 30 percent of the cost of health plan coverage. The court held that the EEOC failed to provide a reasoned explanation for adopting the incentive limit. Rather than vacating the final rules, the court sent them back to the EEOC for reconsideration.

It is unclear how the EEOC will respond to the court’s decision. Due to this new legal uncertainty, employers should carefully consider the level of incentives they use with their wellness programs. Employers should also monitor any developments related to the EEOC’s rules.

Final Wellness Rules

Federal laws affect the design of wellness programs, including two laws that are enforced by the EEOC—the ADA and GINA.

  • Under the ADA, an employer may make disability-related inquiries and require medical examinations after employment begins only if they are job-related and consistent with business necessity. However, these inquiries and exams are permitted if they are part of a voluntary wellness program.
  • Under GINA, employers cannot request, require or purchase genetic information. This includes information about an employee’s genetic tests, the genetic tests of family members, and the manifestation of a disease or disorder of a family member. Like the ADA, GINA includes an exception that permits employers to collect this information as part of a wellness program, as long as the provision of information is voluntary.

For many years, the EEOC did not definitively address whether incentives to participate in wellness programs are permissible under the ADA and, if so, in what amount. Earlier this year the EEOC issued long-awaited final rules, but the court has now remanded the final wellness rules back to the agency for reconsideration.

Sapoznik Insurance will keep you updated with any developments on this matter. In the meantime, please contact your representative with any questions about how these rules may affect you.

This information contained is not intended as legal or medical advice. Please consult a professional for more information.

Do You Need STD Insurance?

For working individuals, a disability is a medical condition that reduces your ability to perform your job duties, usually an injury or illness. While some disabilities are work-related, nearly 75 percent of disabling injuries to workers occur off the job.

Disability insurance is coverage that provides you with income protection, should you lose time on the job due to an injury or illness. With disability coverage, you are compensated for a portion of your lost income.

What Is Short-term Disability Insurance (STD)?

STD is a type of disability insurance coverage that can help you remain financially stable should you become injured or ill and cannot work. Usually, STD coverage begins within one to 15 days of the event causing your disability. The coverage allows you to continue to receive pay at a fixed weekly amount or a set percentage of your income.

STD typically lasts for about 10 to 26 weeks, although this varies by policy. When this STD coverage ends, long-term disability (LTD) coverage typically takes effect.

Why Is Disability Insurance So Important?

The risk of disability is greater than most employees realize. When you become disabled and lose time at work, your source of income is eliminated. Nearly one-third of employees will miss more than one month of pay due to injury or illness. In addition to lost income, you are most likely experiencing an increase in medical expenses due to your disabling injury or illness.

What Is Supplemental Disability Insurance?

Disability insurance is coverage that provides you with income protection, should you lose time on the job due to an injury or illness.

Traditional medical insurance doesn’t cover every expense related to an injury or illness. Bills and expenses can continue to add up, especially if you have to stop working for a period of time and lose your income.

Supplemental insurance is additional coverage that can help you pay deductibles or copayments and other increasing medical costs not covered by your employer-sponsored insurance plan.

 

What is Long-term Disability Insurance?

 

 

For working-age individuals, disability refers to a medical condition that reduces your ability to perform your job duties. Disability insurance is coverage that provides you with income protection should you lose time on the job due to an injury or illness. With disability coverage, you receive partial replacement of lost income.

What Is Long-term Disability Insurance (LTD)?

LTD is a type of disability insurance coverage that pays employees a set percentage of their regular income after a specified waiting period. For example, if a worker is covered under short-term disability (STD) insurance as well, the LTD insurance would kick in once the STD policy is exhausted, typically after three to six months.

LTD insurance protects workers in the event they become disabled for a prolonged period prior to retirement. LTD policies are often offered through employers as part of a standard benefits package.

The length of LTD plans varies; some may be limited to a period between two and 10 years, while other plans continue paying out until age 65.

Why Is Disability Insurance So Important?

The risk of disability is greater than most employees realize. When you become disabled and lose time at work, your source of income is eliminated. In addition to lost income, you are most likely experiencing an increase in medical expenses to deal with your disabling injury or illness.

What Is Supplemental Disability Insurance?

Traditional medical insurance doesn’t cover every expense related to an injury or illness. Bills and expenses can continue to add up, especially if you have to stop working and lose your income.

In addition, the policy offered by your employer may not be enough to cover your financial needs in the event of a disability. Supplemental insurance is additional coverage that can help you pay whatever expenses may not be covered by your medical plan or employer’s disability policy.

If you decide that the coverage offered through your employer-sponsored group plan does not adequately fill your personal needs, you should contact an independent agent or carrier to inquire about individual disability insurance coverage.

Open Enrollment Glossary of Terms

Open enrollment is the time of year reserved for you to make changes to your benefit elections, and unfamiliar terms can make this process confusing. Use these definitions of common open enrollment terms to help you navigate your benefits options.

Coinsurance – The amount or percentage that you pay for certain covered health care services under your health plan. This is typically the amount paid after a deductible is met, and can vary based on the plan design.

Consumer-driven (also known as consumer-directed or consumer choice) Health Care (CDHC) – Health insurance programs and plans that are intended to give you more control over your health care expenses. Under CDHC plans, you can use health care services more effectively and have more control over your health care dollars. CDHC plans are designed to be more affordable because they offer reduced premium costs in exchange for higher deductibles. Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs) are common examples of CDHC plans.

Copayment – A flat fee that you pay toward the cost of covered medical services.

Covered Expenses – Health care expenses that are covered under your health plan.

Deductible – A specific dollar amount you pay out of pocket before benefits are available through a health plan. Under some plans, the deductible is waived for certain services.

Dependent – Individuals who meet eligibility requirements under a health plan and are enrolled in the plan as a qualified dependent.

Flexible Spending Account (FSA) – An account that allows you to save tax-free dollars for qualified medical and/or dependent care expenses that are not reimbursed. You determine how much you want to contribute to the FSA at the beginning of the plan year. Most funds must be used by the end of the year, as there is only a limited carryover amount.

At open enrollment time, you have many decisions to make. Don’t let confusing terms trip you up. Refer to this handy list of commonly used terms.

Health Management Organization (HMO) – A type of health insurance plan that usually limits coverage to care from doctors who work for or contract within a specified network. Premiums are paid monthly, and a small copay is due for each office visit and hospital stay. HMOs require that you select a primary care physician who is responsible for managing and coordinating all of your health care.

Health Reimbursement Arrangement (HRA) – An employer-owned medical savings account in which the company deposits pre-tax dollars for each of its covered employees. Employees can then use this account as reimbursement for qualified health care expenses.

Health Savings Account (HSA) – An employee-owned medical savings account used to pay for eligible medical expenses. Funds contributed to the account are pre-tax and do not have to be used within a specified time period. HSAs must be coupled with qualified high-deductible health plans (HDHP).

High Deductible Health Plan (HDHP) – A qualified health plan that combines very low monthly premiums in exchange for higher deductibles and out-of-pocket limits. These plans are often coupled with an HSA.

In-network – Health care received from your primary care physician or from a specialist within an outlined list of health care practitioners.

Inpatient – A person who is treated as a registered patient in a hospital or other health care facility.

Medically Necessary (or medical necessity) – Services or supplies provided by a hospital, health care facility or physician that meet the following criteria: (1) are appropriate for the symptoms and diagnosis and/or treatment of the condition, illness, disease or injury; (2) serve to provide diagnosis or direct care and/or treatment of the condition, illness, disease or injury; (3) are in accordance with standards of good medical practice; (4) are not primarily serving as convenience; and (5) are considered the most appropriate care available.

Medicare – An insurance program administered by the federal government to provide health coverage to individuals aged 65 and older, or who have certain disabilities or illnesses.

Member – You and those covered become members when you enroll in a health plan. This includes eligible employees, their dependents, COBRA beneficiaries and surviving spouses.

Out-of-network – Health care you receive without a physician referral or services received by a non-network service provider. Out-of-network health care and plan payments are subject to deductibles and copayments.

Out-of-pocket Expense – Amount that you must pay toward the cost of health care services. This includes deductibles, copayments and coinsurance.

Out-of-pocket Maximum (OOPM) – The highest out-of-pocket amount paid for covered services during a benefit period.

Preferred Provider Organization (PPO) – A health plan that offers both in-network and out-of-network benefits. Members must choose one of the in-network providers or facilities to receive the highest level of benefits.

Premium – The amount you pay for a health plan in exchange for coverage. Health plans with higher deductibles typically have lower premiums.

Primary Care Physician (PCP) – A doctor that is selected to coordinate treatment under your health plan. This generally includes family practice physicians, general practitioners, internists, pediatricians, etc.

Usual, Customary and Reasonable (UCR) Allowance – The fee paid for covered services that is: (1) a similar amount to the fee charged from a health care provider to the majority of patients for the same procedure; (2) the customary fee paid to providers with similar training and expertise in a similar geographic area, and (3) reasonable in light of any

 

 

 

Understanding a Health Savings Account

What is a health savings account?

Otherwise known as an HSA, a health savings account can be funded with your tax-exempt dollars, by your employer, by a family member or by anyone else on your behalf. Dollars from the account can help pay for eligible medical expenses not covered by an insurance plan, including the deductible, coinsurance, and even health insurance premiums, in some cases. 

Who is eligible for an HSA?

Anyone who is:

  • Covered by a high-deductible health plan (HDHP)
  • Not covered under another medical plan that is not an HDHP
  • Not entitled to (eligible for AND enrolled in) Medicare benefits; or
  • Not eligible to be claimed on another person’s tax return.

What is a high deductible health plan (HDHP)?

A high-deductible health plan is a plan with a minimum annual deductible and a maximum out-of-pocket limit as listed in the following table. These minimums and maximums are determined annually by the Internal Revenue Service (IRS) and are subject to change.

Type of Coverage

Minimum Annual Deductible

Maximum Annual Out-of-pocket

Individual

$1,300 for 2017

$1,350 for 2018

$6,550 for 2017

$6,650 for 2018

Family $2,600 for 2017

$2,700 for 2018

$13,100 for 2017

$13,300 for 2018


How does an HSA work?

Part 1: Qualifying High Deductible Health Insurance Plan

Provides health care benefits after the deductible has been met.

Part 2: Health Savings Account

Pays for out-of-pocket expenses incurred before the deductible is met.

 What are the steps in an HSA?

  1. Employee, employer, family member and/or someone else funds the employee’s HSA account.
  2. Employee seeks medical services.
  3. Medical services are paid by HDHP, subject to deductible and coinsurance.
  4. Employee may seek reimbursement from HSA account for amounts paid toward deductible and coinsurance.
  5. Deductible and out-of-pocket maximum fulfilled.
  6. Employee may be covered for all remaining eligible expenses.*

The HDHP can provide preventive care benefits without the required minimum deductible.

*Subject to plan design; check your HDHP Summary Plan Description.

When do I use my HSA?

After visiting a physician, facility or pharmacy, your medical claim will be submitted to your HDHP for payment. Your HSA dollars can be used to pay your out-of-pocket expenses (deductibles and coinsurance) billed by the physician, facility or pharmacy, or you can choose to save your HSA dollars for a future medical expense.

You may also be able to use an HSA debit card to access your HSA funds, if your HSA custodian or trustee allows it.

You may use your HSA for non-medical expenses. However, HSA amounts that are used for non-medical expenses are taxable as income to you and are generally subject to an additional 20% penalty.

What is a deductible?

It is a set dollar amount determined by your plan that you must pay out-of-pocket or from your HSA account before insurance coverage for medical expenses can begin.

How much can I contribute to an HSA?

The annual HSA contribution limits for 2017 are:

  • $3,400 for individual coverage and $6,750 for family coverage

The annual HSA contribution limits for 2018 are:

  • $3,450 for individual coverage and $6,900 for family coverage

Individuals age 55 or older may be eligible to make a catch-up contribution of $1,000.

What is the difference between an HSA and Flexible Spending Account (FSA)?

  • An HSA can roll over unused funds from year to year and is portable if the employee leaves the company.
  • An FSA cannot roll over unused funds from year to year and is not portable.

 

Can I contribute to both an HSA and an FSA in the same year?

General purpose FSA coverage will make you ineligible for HSA contributions. However, certain types of FSA designs will not prevent your HSA eligibility.  For example, if you are covered under a “limited FSA” (for example, an FSA that covers vision, dental and/or preventive care expenses on a first-dollar basis), you can be eligible for an HSA.

Also, you can be eligible for an HSA if you are covered under a “post-deductible FSA” (that is, an FSA that only pays or reimburses for preventive care or for medical expenses that are incurred after the minimum annual HDHP deductible has been met).

Please ask if a limited or post-deductible FSA is available to you.

 What if I enroll in an HSA in the middle of the year?

Your HSA contributions are generally determined on a monthly basis. However, if you enroll in an HSA mid-year, you are allowed to make a full year’s contribution, provided you are eligible on Dec. 1 of that year and you remain eligible for HSA contributions for at least the 12-month period following that year.

Why should I elect an HSA?

  1. Cost Savings
  • Triple tax benefits
  • HSA contributions are excluded from federal income tax
  • Interest earnings are tax-deferred
  • Withdrawals for eligible expenses are exempt from federal income tax
  • Reduction in medical plan contribution
  • Unused money is held in an interest-bearing savings or investment account

Note: Many states have not passed legislation to provide favorable state tax treatment for HSAs. Therefore, amounts contributed to HSAs and interest earned on HSA accounts may be included on the employee’s W-2 for state income tax purposes.

  1. Long-term Financial Benefits
  • Save for future medical expenses.
  • Funds roll over from year to year.
  • Account is portable—you take it with you even if you leave the company.
  1. Choice
  • You control and manage your health care expenses.
  • You choose when to use your HSA dollars to pay your health care expenses.
  • You choose when to save your HSA dollars and pay health care expenses out-of-pocket.
  • You decide whether to use your HSA dollars to pay for non-medical expenses and incur the additional taxes.