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Health Insurance

Health Insurance


Health insurance helps pay medical bills and expenses in the event you are injured, become sick, or otherwise need medical care or attention. Many policies also cover preventative, or "well care," paying for routine exams and checkups to help you maintain good health by increasing the chances your doctor will detect any concerns early, while treatment options are easier, more effective, and less costly. Health insurance is available to groups and individuals and includes a range of different policy types, including Major Medical, supplemental, Medicare, Long Term Care, and Dental.

Health insurance is designed to shift a portion of both the risk and the expense of potential medical costs from individuals to an insurance company. The more risk and expense you want to pass on to an insurance carrier, the higher the cost of premiums. No policies available today will shift all of your medical expenses to the insurance company, and some risk is retained by the policy owner in the form of deductibles, co-insurance, and co-pays. By adjusting the combination and level of these features, premium amounts vary widely and allow for some type of coverage to be found that will fit in most any budget.

Many people are concerned more about the "catastrophic" type of medical expenses caused by a prolonged major health issue, surgery, or a hospital stay, and choose plans that primarily will limit the amount of "out-of-pocket" expenses to a manageable level, no matter how high their claims may be. Others want to additionally cover their routine doctor bills and prescription drug costs as much as possible. Whatever your goal of coverage may be, you will need help in figuring out the difference in plans and companies. Let our agents help you sort through this maze so you can find a plan that is right for you. At Blue Atlantic Group, our agents are not just insurance experts; they are your neighbors and friends.

Group vs. Individual Health Insurance

Group health insurance can only be purchased by a company, certain organizations, or in some cases, an affinity group; and then employees, owners, members, or people with a direct relationship with the group can apply for coverage under the group plan. It is the determination of the company or organization who set up the group plan on how much of the premium they will pay on behalf of their employee or their employees' families, if any at all. Group plans are regulated differently than individual plans, and group plan rules vary depending upon the state, the size of the group, the insurance company underwriting the plan, and the business sponsoring the plan. While there are presently no requirements that group health insurance must be offered by a company or that the company must pay the premium for their employees, there are regulations that ensure fairness that benefits offered are made available to all members of the group equally. If you do not have access to a group plan, or your group plan premium is not acceptable, then your option is to purchase private individual insurance.

COBRA or State Continuation

If you have been covered under a group plan and leave the company, the company MUST offer you the option of paying your own premiums in order to continue the same coverage for a determined period of time, which usually ranges from 12-36 months. The premium you would pay during this period is not the same as the group premium paid while employed and will likely be much higher, but the coverage should remain the same. The size of the group will determine which set of rules will govern your continuation of insurance options, and the insurance company will determine how much your COBRA premium will be. The purpose of COBRA is to allow people to keep their health coverage while they find new employment, or during any waiting periods imposed at their new company before new group coverage will become effective. Moving from one group plan to another, directly or through COBRA, retains the insurability of the employee the same from one insurance company to the next, even though the plans and/or companies are changing. All medical conditions covered under the previous group plan will continue to be covered under the new plan with no new pre-existing exclusion or waiting period imposed. If COBRA or group coverage is broken, however, with a lapse of 61 days or more, then the new insurance company can fully underwrite an application of a new employee, and pre-existing condition exclusions can be imposed.

The benefits and features of group insurance coverage is nearly the same as individual insurance, but the use and placement of group insurance plans fall under completely different regulations. The following discussions about different types of health insurance will provide some useful information about health insurance in general, but will only be focused on its application in an individual plan. If your company needs help to set up, review, or change their group plan, contact Blue Atlantic Insurance Group for a personal consultation.

Major Medical


Comprehensive health insurance that covers you for everything from doctor visits to hospital stays is called Major Medical Insurance. Policy offerings vary greatly from company to company and from plan to plan. The combinations of varying deductibles, co-insurance amounts, total out-of-pocket expenses, and co-pays will all impact the level of premiums each plan will cost. Current health and use of tobacco are also factors which influence the cost of determining health insurance premiums for an individual. Insurance companies are allowed to determine both policy benefits and premium costs, but every plan they propose to offer must be reviewed and approved by each state insurance department where the policy will be sold. This large choice of options makes it possible for people to customize a plan by searching through the wide number of plans available, but it makes comparing plans from one company to the next very difficult, and nearly impossible without the assistance of a knowledgeable insurance professional. Blue Atlantic Insurance Group agents can take the confusion out of shopping for health insurance and help you find the coverage you need, with a quality carrier, at a budget that you can afford.

Important Health Insurance Terminology


Deductible - The deductible is the amount of money you must pay first, before the insurance company begins to pay benefits provided under your policy. The deductible can be met from one large expense, or from the accumulation of several qualified medical bills. Even though you pay the deductible, claims must still be filed with the carrier so they can keep track of how much of your deductible has been met in each deductible period and will know when to begin paying claims on your behalf. The insurance company will make the determination of what is included as a deductible expense, but generally, if it is a covered medical expense under your policy, it will be counted toward your deductible. Some coverage benefits are excluded from the deductible requirement and are covered immediately subject to co-pays, such as doctor visits, routine exams, emergency room or urgent care visits, or prescription drug benefits. High deductible plans without co-pay features essentially will only provide coverage in the event of a claim larger than the deductible amount. Most deductible periods are on a calendar schedule and reset to 0 at the beginning of each new calendar year.

Co-Insurance - In most plans, once the deductible is met, the insurance company begins paying benefits at some percentage of the actual expense. If your co-insurance percentage is 100%, it means that once you have met your deductible, the insurance company begins paying the entire amount of any medical expenses you incur for the remainder of the year. If the co-insurance percentage is less than 100%, then the difference is the co-insurance amount that you must pay. For instance, if your deductible has been met and your co-insurance is 80%, that means that for the next bills submitted, the insurance company will pay 80% of the expense, and you are responsible to pay the co-insurance amount of 20% of the expense. Most co-insurance amounts are capped with an out-of-pocket yearly maximum.

Out-of-Pocket Maximum - when you share in the cost of your medical expenses after the deductible has been met through the use of co-insurance, the insurance company will limit the amount you will have to pay in co-insurance in a given year through the use of an out-of-pocket maximum. Once the out-of-pocket maximum has been reached, the insurance begins to pay 100% of your qualified medical bills for the remainder of the year. Like the deductible, the out-of-pocket maximum resets to 0 at the beginning of each calendar year. To evaluate the total amount of financial risk a health plan might cost you in a year with high claims, simply add the out-of-pocket maximum to the deductible. Except for unusual claims that may not be covered under your policy, or co-pays, the sum of the deductible and the out-of-pocket maximum is the limit of how much you would be responsible for financially in the event of a very large claim year. In addition to finding a premium you can afford, make sure to consider this figure as well when determining which health plan gives you the amount of protection you seek.

Co-Pay - Co-pays are the amount you pay each time a service is rendered, are not based upon the cost of the bill, and are not due unless the service is utilized. Certain medical services, in office procedures, doctor visits, prescriptions, or facility uses have been separated out in some health policies, and are not part of the deductible and co-insurance calculations. These covered benefits are subject to co-pays each time you utilize the service, regardless of how much the service actually cost. For instance, doctor visit co-pays often include the examination and any diagnostic services provided in the doctor's office for one co-pay amount. Most providers require co-pays be paid at the time of visit, and will bill the insurance company for any additional amounts. After you have paid your co-pay to the provider, the insurance company is responsible for any excess amounts charged during that visit. Co-pays offer an incentive for people to seek medical attention as often as needed, since the cost of the visit to the insured is known ahead of time, and no deductible has to be met before benefits are received. Many plans, which include prescription drug benefits, also use a tiered co-pay schedule for each filling and refill of a prescription drug.

In-Network/Out-of-Network-Most insurance plans use some type of pre-defined network of doctors and providers in order to offer the full benefits under a health insurance policy. Insurance companies contract with doctors, hospitals, facilities, and pharmacies to establish the rates they will pay for each service provided. Because of this agreement between the providers and the insurance company, the carrier can control costs and clearly define the benefits offered in your plan in a given policy year. Even though your plan may be subject to the use of providers included in the network in order to receive maximum benefits, there is often (but not always), an out-of-network provision where you are still covered under your plan if you go out-of-network, but with a loss of benefits, higher deductibles and co-insurance, or other limitations on coverages. If your plan is subject to a network, you need to understand how it works within your policy and verify if your existing doctors and providers will be in-network, or out-of-network.

Supplemental Insurance


This type of insurance refers to the use of additional policies to cover "gaps" in coverage received from another policy or other source, and many offer benefits not typically found in Major Medical insurance policies, such as payment for loss of income or for living expenses during an injury or prolonged illness. Some types of supplemental insurance simply pay you a lump sum of cash upon diagnosis of a number of named "dread" diseases, such as cancer, heart attack, or stroke, or will pay you cash if you have an accident. Others will directly pay you a daily amount of money if you are confined in the hospital. Supplemental insurance policies are not tied to your medical insurance and are not paid to the provider, so you can use the proceeds you receive from these policies in whatever manner you need or desire.

Should I Buy Supplemental Health Insurance?

If you have Major Medical insurance but are concerned that it will not be sufficient in the event of a major claim, or you have high deductibles and co-insurance, then you may want to consider supplemental insurance products. These policies do not usually require a medical exam, and the premiums are priced affordably so that they could offer you peace of mind and help you handle a large claim or serious illness without placing your family at financial risk.

Three main types of supplemental health policies:

  1. Hospital indemnity-This kind of policy offers cash benefits if you become hospitalized. Payments are made directly to you, or a beneficiary if you prefer, and can be paid monthly, weekly, or daily. There may be a minimum number of days you have to be confined before these benefits begin to pay.
  2. Disease specific-This kind of supplemental policy pays you a lump sum benefit if you are diagnosed with a major disease, such as cancer, stroke, or heart attack. Payments can be made periodically if desired, or in a single payment, depending upon the policy. Policies are available to cover single or multiple diseases.
  3. Accidental policy-This kind of insurance pays you, (or your beneficiary in the event of your death) a cash benefit if you should incur injury due to an accident as defined in the policy. The payment may vary depending upon the severity of the accident, the permanence of any loss of use of sight or limbs, or other limitations as outlined in the policy.

Supplemental insurance can help you fill the gaps in your medical insurance program, but is not intended to be a replacement or substitution for a good major medical health plan. The agents at the Blue Atlantic Insurance Group can help you determine what levels of coverage and which combination of plans best suit your needs and budget.

Long Term Care Insurance


Long Term Care Insurance, or LTC, as it is often called, covers the high costs of service in the event that you are confined to a nursing home for a prolonged period of time, and often includes a provision for you to receive benefits for having that care provided in your home. Unlike Medicare, LTC insurance will cover you whether you need skilled or convalescent care for as long as policy benefits last. In choosing a LTC policy you need to decide on five different levels of benefits that allow you to customize coverage and control premiums:

Daily benefit amount-should represent the amount of the current nursing home cost you wish to cover based upon this expense in your area.

Benefit period-defined by the number of years you want the coverage to last once you begin claims; ranges from 1 year to lifetime.

Amount of the daily benefit allowed for home health care-from 0% to 100%, this determines how much you will receive to pay for professional in home care, if you so choose.

Inflation protection--This determines the compounding method, if any, of the daily amount to allow this benefit to increase over time between when you purchase the policy until you being making claims against the policy.

Elimination period-This is the number of months after you meet the qualification for payment of benefits, before the benefits will begin to pay. Many people try to match the possibility that Medicare will cover the first 100 days of a stay, so they choose a similar elimination period for the LTC insurance to pick up after that period of time. The longer the elimination period chosen, the lower the premiums will be.



How you receive benefits from a LTC Policy


LTC policies use a trigger of the loss of several independent functions, referred to as activities of daily living (ADL), as the mechanism that qualifies a policy holder for benefits and usually requires a doctor to confirm this loss. Different insurance companies can vary the number of lost ADLs required to begin benefits, but typically it is a loss of two from a list of five or six items, such as:

  • Bathing
  • Dressing
  • Using the toilet
  • Transferring (to or from the bed or chair)
  • Incontinence
  • Eating

Once you begin receiving benefits under a LTC policy, the provider works directly with the insurance company to receive ongoing payment for services, and you will be billed directly by the nursing home for any shortages between the cost and the payment received from your policy.

Purchasing a LTC Policy

Many people consider LTC Insurance as an ideal means to protect assets from erosion in the event of a prolonged stay in a nursing home or long term use of home health care services. The insurance policy provides a large sum of money to help pay for these high costs to keep the individual from having to sell off assets, liquidate investments, or divert income needed to support a stay at home spouse. Having a LTC policy adds choices of where and when care is received, and helps the individual maintain some degree of independence and dignity for much longer, as they need more and more personal and medical assistance with the ADLs.

The reason more people do not purchase this valuable insurance is that you must qualify for it by a stringent health underwriting process, and many people delay seeking the purchase of LTC insurance until after they have developed health conditions which prohibit them from obtaining it, or else their health affects the cost to them and puts premiums out of reach. After the level of benefits, age and health are the greatest factors in the determination of the premium costs, and since LTC insurance is health insurance, it can go up in the future if the insurance company determines it needs to raise rates in order to continue to provide benefits to policy holders. The good news is individual rates cannot be raised, and your policy cannot be canceled as long as you continue making your premium payments, no matter what changes you may have in your health or condition.

The other deterring factor which keeps people from buying LTC insurance is the cost. The premiums are high for people on a fixed or limited income, and the justification that they may never need it often convinces them that they would be better off taking their chances and keeping that premium for other things. There are "return of premium" options available, for a cost, on some LTC policies for those who want all the security of LTC insurance without risking the loss of the premium dollars if no claim is ever made, but this option only further increases the ongoing premium expense.

There is no single right answer to the dilemma of whether to risk premium dollars or the possible enormous expense of a nursing home stay, but the decision needs to be made with ALL the facts and information. Blue Atlantic Insurance Group has agents who are experts in the area of LTC insurance and can help you determine if one of these policies is right for you. Our agents also have planning techniques and other insurance products which can help people to better "self insure" against the high cost of nursing home stays, by strategically using assets in a way that does not interfere with income needs, and ensures that any unused amounts are left for transference to heirs and beneficiaries.

Since this type of planning is so individual, we cannot give you an off the shelf plan to meet your needs, and one size does not fit all. Let our professional agents gather the facts and create a customized plan that helps you enjoy your retirement to the fullest, while also preparing for the potential of any circumstance or expense that the future may hold. At Blue Atlantic Group, our agents are not just insurance experts; they are your neighbors and friends.

Dental Insurance


Many company health benefits offer an option for employees to elect group dental coverage at a reasonable cost. If you have had dental insurance under a group plan in the past and are looking for individual dental insurance now, you will find that coverage under these individual plans will be limited and costly, but they are available. Since most individual medical plans only cover dental work when there is a medically based need, such as disease or injury to the jaw or mouth, without a separate dental policy, many people are left to cover dental expenses on their own, which motivates them to seek out dental insurance. There are also some discount dental plans available that are not insurance based, but are simply a pooled agreement between the company offering "membership" and certain dental providers who agree to discount their services to those who carry the membership card. True dental insurance involves an insurance company, who will typically pay the provider directly for any approved benefits.

Most individual dental insurance is divided into three levels of coverage:

  1. Preventative-includes scheduled exams, cleanings, and x-rays
  2. Basic-includes fillings, extractions, minor surgery, etc.
  3. Major-includes root canals, crowns and inlays, dentures, and bridges

Private dental plans usually cover preventative care completely to encourage good dental health, but have waiting periods and co-insurance for basic and major work to discourage someone from obtaining coverage, receiving policy benefits for major work, then dropping the policy. Most individual plans do not cover orthodontics or only cover a very limited amount and all plans have an annual maximum benefit paid for each covered individual. To evaluate whether a dental plan makes sense for you and your family, let Blue Atlantic Insurance Group help. At Blue Atlantic Group, our agents are not just insurance experts; they are your neighbors and friends.

    Let Blue Atlantic Insurance Group facilitate the search for the best dental insurance policy for you.

    We are Blue Atlantic Insurance Group.

    Call us Today! 919-612-7450