Individual & Family
What is the best healthcare plan for me?
Choosing between different health insurance plans isn’t always simple. Unfortunately, there is no one “best” plan for everyone. The best match for you and your family may be different than the best match for someone else. In order to help you answer this question, here are a few things to consider:
1) Are you going to need long-term coverage or just something for the short-term?
If you’re between jobs for 1-6 months, you may want to look into our short-term coverage options.
2) Are you looking for basic “catastrophic” coverage or more comprehensive coverage?
Some insurance plans offer basic ”catastrophic” coverage (i.e., primarily inpatient hospitalization and outpatient surgery coverage) to cover you in case of a major accident or illness. These insurance plans typically have higher deductibles with lower monthly premium than plans with more comprehensive coverage, and may be appropriate for people who intend to use their insurance primarily in the event of a serious accident or illness.
Other insurance plans, in addition to offering coverage in case of a major accident or illness, offer more comprehensive coverage which MAY include benefits such as: preventative care, physician services, prescription drug benefits and routine office visits. These insurance plans typically have a higher monthly premium than plans that only offer basic coverage, and may be appropriate for people who intend to use their insurance on a regular basis.
The Patient Protection and Affordable Care Act (PPACA) requires that all plans must provide coverage for certain preventive benefits, immunizations, and screening, without cost sharing requirements for plan/policy years beginning on or after September 23, 2010. This rule does not apply to grandfathered plans.
3) Would you rather pay for your services before you use them or when you use them?
Typically, the higher the monthly premium that you pay, the less you will pay per doctor’s visit in co-payments and deductibles. If you choose a health insurance plan with a low monthly premium, you’re likely to have a higher co-payment or deductible. If you don’t anticipate making frequent use of your health insurance coverage, a higher-deductible plan with a lower monthly premium may suit you best.
4) How important to you is easy access to specialists?
HMO Health insurance plans that require you to coordinate your care through a primary care physician typically require that you obtain a referral before seeing a specialist. Thus, if you prefer easier access to specialists, you may wish to consider a PPO plan.
5) Do you have a specific doctor or hospital that you would like to visit for healthcare?
Some insurance plans utilize provider networks. Pay special attention to the network of doctors or facilities that each health insurance plan utilizes. You’ll want to make sure that your favorite doctor or hospital is included on the list for the health insurance plan you choose. Also note that networks utilized by health insurance plans can change, so there is no guarantee that your doctor will always be contracted with your chosen health insurance plan.
6) What is the most you could pay out in case of a serious illness or injury?
Health insurance plans place limits on how much a member is required to pay out of pocket per year for his or her healthcare. This limit is referred to as an out-of-pocket maximum. Once you’ve contributed this maximum amount toward your healthcare, the health insurance company typically covers 100% of all other costs for the remainder of the calendar year. If you’re concerned about what may happen to you in case of a serious illness or injury, you may wish to pay special attention to the out-of-pocket maximums for the health insurance plans you’re considering.
What is an HMO?
Though there are many variations, HMO (Health Maintenance Organizations) plans typically enable members to have lower out-of-pocket healthcare expenses but also offer less flexibility in the choice of physicians or hospital than other health insurance plans. As a member of an HMO, you’ll be required to choose a primary care physician (PCP). Your PCP will take care of most of your healthcare needs. Before you can see a specialist, you’ll need to obtain a referral from your PCP.
With an HMO you’ll likely have coverage for a broader range of preventive healthcare services than you would through another type of plan. You may not be required to pay a deductible before coverage starts and your co-payments will likely be minimal. However, keep in mind that you’ll likely have no coverage whatsoever for services rendered by non-network providers or for services rendered without a proper referral from your PCP
What is a PPO?
A Preferred Provider Organization(PPO), like an HMO, has a network of doctors and hospitals with whom the insurance company has contracted to limit costs to an agreed to amount. Unlike an HMO, PPO participants may choose care from within the PPO network or from providers outside the network and need not obtain a referral to see a specialist. PPO plans typically require you to pay an annual deductible and a co-payment for each service until the maximum out-of-pocket amount is reached after which eligible benefits will be paid at 100%. You will pay less for services from a member of the PPO network than from a non-network provider. For example, you may receive 80 percent of the expenses incurred with a PPO provider and only 60 or 50 percent from non-PPO providers.
A Health Savings Account (HSA) works similar to an IRA, except that funds used to pay eligible medical expenses are with pre-tax dollars (tax-free) with unused funds saved for retirement on a tax-deferred basis. For example, you get a relatively inexpensive high deductible health insurance plan and then a tax-deductible savings account to cover qualified medical expenses including prescription drugs, dental and vision expenses, copayments and deductibles. Annual contribution limits change per federal guidelines every year just like with an IRA. Any unused money in your HSA at the end of the year may continue to grow in your account or may be rolled over to other approved investments where they will continue to grow tax-deferred until used or withdrawn.
What is a co-payment?
A “co-payment” or “co-pay” is a specific charge that your health insurance plan may require that you pay for a specific medical service or supply. For example, your health insurance plan may require a $30 co-payment for an office visit or brand-name prescription drug, after which the insurance company often pays the remainder of the charges.
What is a deductible?
A “deductible” is a specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims. Deductibles can range anywhere from $0 – $6,000. The higher the deductible, the lower the monthly premium.
What is coinsurnace?
Coinsurance is refers to the amount that you are required to pay for a medical claim, apart from any co-payments or deductible. For example, if your health insurance plan has a 20% coinsurance requirement, then a $100 medical bill would cost you $20, and the insurance company would pay the remaining $80. This coinsurance phase only kicks in after you have met your deductible.
What is an Out-of-Pocket Maximum?
The Out-of-Pocket Maximum (OOP) is the most you pay during a calendar year before your plan begins to pay 100% of the allowed amount. This limit does NOT include your premium or services the plan doesn’t cover. Most plans don’t count your doctor’s office co-payments or out-of-network payments toward this maximum. Depending on the plan, annual deductibles may or may not be added into the OOP amount. However, you should always make sure the annual deductible amount is added in to get your true Out-of-Pocket Maximum.
What is the difference between in-network and out-of-network providers?
An IN-network provider is contracted with the health insurance company to provide services to plan members for specific pre-negotiated rates. An OUT-of-network provider is NOT contracted with the health insurance plan. If you visit a physician or other provider WITHIN the network, the amount you will be responsible for paying will be less than if you go to an OUT-of-network provider. For example, if you use an OUT-of-network provider who bills you $500 directly for a recent service because they do not submit claims to insurance, then you would have to submit the $500 claim to your insurance company for reimbursement. The insurance company will only reimburse you a certain % of what they would have paid an IN-network provider for that service. In addition, the OUT-of-network % is usually less than what they would pay for IN-Network providers. For example, the insurance company may only give you 50% of $200 because $200 is the pre-negotiated rate for an IN-network provider for that same service. Therefore, you would only get $100 reimbursed for the $500 the OUT-of-network provider charged you. Therefore, you should always try to use IN-network “Contracted” providers of your insurance plan or you will be faced with higher costs than you anticipated.
When can my Coverage start?
You can request that your Individual and Family health insurance plan start anytime between 1 and 90 days in the future. However, the insurance companies will typically need some time to process your application so keep in mind that the actual date for the start of your coverage may vary depending on the underwriting process and the availability of your medical records. For example, the earliest Anthem will start coverage is 15 days after the day the application is submitted.
What is a PPO dental insurance plan?
A PPO dental plan allows you to use any dentist. However, you will only receive the FULL the benefits of the plan if you use an IN-Network Dentist. Dentists sign up for the PPO network hoping to get more patients to treat. In acknowledgment of the referrals an insurance company provides, the dentists offer lower rates for the clients of a particular dental insurance provider. The result is lower fees for patients. Patients, however, often have to choose from a network of specific dentists or face higher fees or decreased benefits. These plans usually have a maximum benefit ranging from $1K to $2K annually.
What are the Advantages and Disadvantages of PPO Dental Insurance Plans?
People prefer PPO dental coverage for the following reasons:
- Flexibility – PPO dental care allows you the flexibility to see any dentist you choose however, with most plans, you can get additional savings by using a dentist who is part of a the insurance provider’s network. With HMO Plans, you are restricted to the Network of Dentist associated with your plan.
- Low deductible – PPO dental coverage typically gives you a low deductible around $50. Some plans (usually HMO) have no deductible at all. This helps to make your dental coverage affordable.
- Less Hassle for Dentists – PPO dental coverage is preferred by many dentists because dentists get paid sooner and with less hassle through this type of coverage. This can mean that more dentists will agree to be part of a PO network and more eager to work with patients who are part of a PPO plan.
- No Waiting Period – PPO dental coverage usually involves no waiting periods for basic services and preventive care. This allows you to use your plan as soon as you enroll. If you don’t need fillings, crowns or root canals then a dental insurance PPO is the right choice. You can still receive care for those services but there might be a waiting period of three or 12 months depending on the service.
People may prefer HMO dental coverage for the following reasons:
- Lower Premiums - HMO Dental plans usually have much lower premiums than PPO Dental plans.
- Unlimited Benefit – PPO Plans usually have a maximum annual benefit ranging from $1K – $2K a year. HMO plans typically have no maximum benefit.
What is a HMO dental insurance plan?
HMO dental coverage stands for Health Maintenance Organization dental insurance. In HMO dental coverage, dentists in a network have to provide dental care to members of the dental insurance plan they are part of. No eligible patient can be turned away. However, if you want to use a dentist outside the approved network, you must pay your entire dentist’s bill yourself. Dentists that are part of the network are paid once a month by the dental insurance provider. Usually, this payment is a fixed monthly sum per person. An HMO dental plan covers:
- Basic dental services – such as regular dental exams, cleaning, and dental x-rays. Often, these basic services are provided cost-free to individuals covered by the HMO California dental insurance plan
- Other dental procedures – such as dental crowns, bridgework, and dentures. These slightly less common procedures often require that the patient cover some of the cost themselves.
There are several differences between HMO and PPO dental insurance plans. While both can provide affordable dental insurance, HMO plans make it more difficult for patients to seek dentists outside a network. While PPO plans often allow patients to select dentists outside their network, many HMO plans do not. They are completely closed, meaning that you cannot accept financial penalties and see a non-network dentist when you need to.
The most serious difference between HMO and PPO dental insurance, however, has to do with the way that dentists are paid. In a PPO dental insurance plan, dentists who are part of a network agree to lower costs for patients covered by a certain insurance provider, in exchange for the referrals from the dental insurance company that bring them more business. However, dentists get paid in full for the services they provide.
With an HMO dental plan, however, dentists are paid set fees. In some cases, this can mean that the less treatment a dentist provides, the more profitable the arrangement is. Dentists prefer PPO dental insurance plans, so many more join PPO networks. This can mean that patients have fewer dentists to choose from through HMO plans.
What are the main considerations for purchasing a HMO or PPO dental plan?
HMO’s are plans for dental treatment that require you to select a care provider. This doctor/dentist is your primary care giver. You will need get referrals from their office to get any types of specialized treatments done. They will typically send you to a dentist that is within your HMO plan. So if you need braces, you need to get a referral from your primary care dentist to see an an orthodontist.
PPO plans do allow you the flexibility to see who you want when you want, basically you lose the referral portion. So if you need braces, you go directly to the orthodontist of your choice. One thing to look into with PPO plans is the fact that some of these now have preferred provider networks. Meaning you will pay less for services if you use a preferred provider because they already have pricing agreements in place.
HMO’s are good if you are happy with your dentist and they are included with the HMO. You are limited to this one doctor without having a referral. Usually fees are lower which in turns lowers your out of pocket costs.
PPO is good if you like to have the flexibility of going were you want when you want to.
What is the best dental plan for me?
We at Health Insurance “R” Us highly recommend speaking with your Dentist first to see what type of Insurance they accept. If they do accept any HMO insurance, your costs will be lower. However, we find that most popular or highly recommended dentists usually only accept PPO Insurance.
If you are looking for a dentist, we suggest trying an HMO dentist first because your overall costs will be lower. You can find a list of network dentists on the insurance companies website whenever you obtain a quote.
Why do I need Accident Insurance?
Accidents happen and accident insurance can help you pay for the expenses that are not fully covered by your major medical insurance. For Example, Accidental policies can be used to help pay for any deductible your Health Insurance plan may have. Whether it’s a broken bone, a sprain, a car accident, or an allergic reaction, meeting the costs for treatment and recovery after an injury can be challenging. Accident Insurance helps you handle the medical and out-of-pocket costs that add up after an accidental injury. This includes emergency treatment, hospital stays, medical exams, therapy treatments and other expenses you may face, such as transportation and lodging needs.
How are benefits paid out?
You can choose to get cash benefits from the carrier directly. Meaning, you’ll have the cash on hand to help you with expenses incurred due to an injury, to help with ongoing living expenses, or to help with any purpose you choose.
Short Term Insurance
When can my coverage start?
Coverage can start as soon as 24 hours after the application is submitted. If you would prefer to have your coverage start later, you can typically select a date up to 30 days in the future.
How long can I have Short Term Insurance for?
Typical plans can be written for up to 185 days. However, you can re-apply for another short-term plan at the end of your coverage term. Many short-term health insurance plans only allow you to re-apply once.
Why would I want coverage for a limited amount of time?
Some examples of when Short Term Insurance would be needed are:
If you’re between jobs, waiting for coverage from another health insurance plan to start, laid off, on strike, a recent college graduate or seasonal employee.
What happens when I reach the end of my coverage period?
At the end of your coverage term, most health insurance companies will allow you to re-apply for another short-term plan.
Should I pay monthly or make a single payment up front?
For most plans, you have the option of paying in monthly installments or in a single up-front payment. If you have the ability to pay a single up-front payment your premium will often be lower.
We recommend you select “Monthly”, if you:
don’t know exactly how long you will need coverage or don’t want to make a single up-front payment
We recommend you select “Single Up-front Payment”, if you:
know exactly how long you will need coverage for and want a discount on the premium
If you select ” Single Up-Front payment” you will need to specify the duration of your coverage (30-185 days). Also, if you select ” Single Up-Front payment” payment, you will enjoy the convenience of not having to manually cancel your plan at the end of your coverage period, although typically you will not be able to get a refund once coverage starts. If you need short-term health insurance after your specified duration, you will need to re-apply for a new short-term plan.
What if I only need coverage for less than 30 days?
Most short-term health insurance plans have a minimum coverage period of 30 days and they do not issue refunds for partial months of coverage.
International & Travel Insurance
Why is Travel Health insurance so critical for international travel?
Obtaining healthcare in some parts of the world can be tricky. Some hospitals won’t provide any treatment—or won’t allow a patient to be discharged—until the hospital has received a guarantee of payment. Such guarantees are commonly provided by travel insurers, in conjunction with assistance providers, but rarely by other insurers or managed care plans. This means you’ll have to pay in advance, perhaps as much as tens of thousands of dollars, with your credit card. Of course, for this to work the hospital must accept foreign credit cards and your card must have a sufficient credit limit.
In addition, remember that leaving your destination—for a place with higher quality medical care or to return home where your regular insurance is accepted—can be difficult. Medical evacuations are tricky to arrange and there are some air ambulance providers who should be avoided. Worse, local authorities may have financial ties to certain evacuation companies. The solution? Most travel insurance includes a medical assistance benefit, which is critical. It gives you 24/7/365 access to a company that will arrange an evacuation for you with a creditable evacuation company–or, through their medical personnel, can help assure that you’re getting appropriate treatment locally. The assistance company will also be available to help with other travel related problems such as legal troubles, lost passports or credit cards, etc. Emergencies are rare but everyone should have a contingency plan.
Are pre-existing conditions covered?
Yes, pre-existing conditions are covered. However, there are some exclusions. The following conditions are typically not covered under Travel Health Plans.
- Pregnancy or Maternity care
- Mental, Emotional of Functional Nervous Conditions or Disorders
- Drug, alcohol, or other substance addiction or abuse
- Dental services
- Vision services
The General Rule is that services that are not Medically Necessary as defined by the Insurer will NOT be covered.
What is the difference between a routine eye exam and a contact lens exam?
Routine eye exams are an important preventive measure for maintaining your overall health and wellness. During an eye exam, your doctor can look for vision problems and signs of serious medical conditions such as glaucoma, cataracts, diabetes, and even cancer.
During a contact lens exam, your doctor will evaluate your vision with contacts. Although your vision may be clear and you feel no discomfort from your lenses, there are potential risk factors with improper fitting of contact lenses that can affect the overall health of your eyes.
Do I need to get a eye exam on a regular basis?
Yes, annual eye exams are highly recommended. Thorough eye exams are essential, not just for detecting vision problems, but as an important preventive measure for maintaining overall health and wellness. It does more than just help you see well. It can also help your doctor see signs of common health conditions like high cholesterol, high blood pressure and diabetes. Caring for your eyes should always be a part of your regular healthcare routine.
I am turning 65 this year, what should I do?
Here are two things you need to do.
- Call Social Security (800) 772-1213 to enroll in Medicare Part A & B. You can enroll as early as four months before you 65th birthday.
- Call us at (800) 300-0205 for quotes on additional Medicare insurance because Medicare only covers 80% of your Hospital and Medical Insurance costs with no prescription drug benefits.
What is Medicare?
Medicare is a federal health insurance program that covers millions of Americans. In general, you are eligible for Medicare if you are 65 or older, or you are younger than 65 and meet criteria for certain disabilities. Read more >
How & When Do I Enroll in Medicare?
You can enroll in Medicare during the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. You can sign up for Medicare by visiting the Medicare Online Application website or by calling Social Security at 1-800-772-1213 Monday through Friday, 7 a.m. to 7 p.m.
You are eligible for Medicare benefits if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years or older and a citizen or permanent resident of the United States. If you aren’t yet 65, you might also qualify for coverage if you have a disability or with End-Stage Renal disease (permanent kidney failure requiring dialysis or transplant).
Here are some simple guidelines. You can get Part A at age 65 without having to pay premiums if:
- You already get retirement benefits from Social Security or the Railroad Retirement Board.
- You are eligible to get Social Security or Railroad benefits but haven’t yet filed for them.You or your spouse had Medicare-covered government employment.
If you are under 65, you can get Part A without having to pay premiums if you have:
- Received Social Security or Railroad Retirement Board disability benefits for 24 months.
- End-Stage Renal Disease and meet certain requirements.
While you don’t have to pay a premium for Part A if you meet one of those conditions, you must pay for Part B if you want it. For reference, the Part B monthly premium in 2013 was $104.90.
Note: You will be eligible for Medicare when you turn 65 even if you are not eligible for Social Security retirement benefits.
If you have any other questions about your eligibility for Medicare Part A or Part B, or if you want to apply for Medicare, please call Social Security at 1-800-772-1213 or apply online via the Medicare Online Application website.
What Is Social Security?
Social Security is the foundation of long-term financial support for almost every American. Think of Social Security as a set of protections against things that threaten your ability to survive financially. These protections can provide crucial financial security for workers, their immediate family members, and even divorced spouses. For example, Social Security benefits may go to
- People who retire and their dependents, typically spouses, but potentially children and grandchildren
- People who are disabled and the immediate family members who depend on them
- Spouses, children, and even the parents of breadwinners who die
Social Security’s guaranteed monthly payments, set by legal formulas, stand out in a world of vanishing pensions, risky financial markets, battered home values, and rising healthcare costs. Although the program faces a potential financial shortfall in the future, its most fundamental features are not expected to change. Social Security combines other distinctive features that you usually don’t find all in one place. These traits are worth keeping in mind when you’re trying to get a handle on what the program is worth to you:
- Benefits are earned. After you meet the requirements for eligibility (ten years of earnings), you’ve established your right to a guaranteed benefit, which also may extend to your dependents.
- Benefits are portable.Your benefits reflect earnings in various places of employment during your working life. They aren’t typically reduced when you change jobs, because most jobs are covered.
- Benefit levels are guaranteed. Social Security benefits are paid under legal formulas and don’t rise or fall based on investment performance, the fortunes of your employer, the direction of interest rates, or other forces over which you have no control.
- Benefits are universal. Social Security covers the rich, the poor, and the middle class.
- Benefits are protected against inflation. Without such protection, rising prices can take a huge toll on fixed income.
If you have more questions about Social Secruity and/or whether or not you qualify, please call Social Security at 1-800-772-1213.
It depends on your Health. You can always apply for a Medicare Supplement plan, but you are not guaranteed acceptance unless it is during your Initial Enrollment Period (7 month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65). Otherwise, you will most likely be subject to Medical underwriting. Which means the insurance company can deny you coverage if you are in poor health. So if you believe there is a chance you will prefer to have a Medicare Supplement (Medigap) plan in the future, we would highly recommend purchasing a Medicare Supplement plan now even though it costs more than a Medicare Advantage plan. The primary reason Medicare Supplements are higher in premium is due to the freedom you have to use any Medicare provider in the nation.
What is the Medicare Open Enrollment Period?
If you currently have Medicare, you can change your coverage choice once a year during the Medicare Open Enrollment Period (OEP). The OEP starts on October 15 and ends on December 7 every year. The OEP is also known as the Annual Enrollment Period (AEP). You will often see both of these terms can used interchangeably. Read More >
What is the Birthday Rule for Medicare Supplement plans?
Medicare may be a federal program, but California has a great Medicare Supplement (Medigap) law known as the “Birthday Rule”. This rule gives Californians the option of changing their Medicare supplement with NO Medical Underwriting for up to 30 days following their birthday. Here are more specifics on how the rule works: Read More >
What is NOT covered by Medicare?
Original Medicare (Part A & B) does NOT cover everything. For example, it only covers 80% of Medicare approved services. This is why many people add prescription drug coverage (Part D) and Medicare Supplement insurance OR purchase a Medicare Advantage plan that includes prescription drug coverage. After purchasing the additional coverages stated above, you are essentially fully covered for most Medicare approved services. However, you may be subject to some small deductibles and copays depending on which plan you select. Nevertheless, there are generally some services that will not be covered no matter what type of additional coverage you purchase. Here is a list of services that are not covered by Original Medicare (Part A & B) and thus will most likely not be covered by a Medicare Supplement (Medigap) plan. Read More >
What is a Medicare Supplement (Medigap)?
Medicare supplement insurance (aka Medigap) helps pay some or all of the health care costs that Original Medicare Parts A and B do not cover. Part A & B cover generally 80% of the costs and Medicare Supplement plans pick up the remaining 20%. So Medicare supplement insurance is meant to be used in combination with Original Medicare. If you receive your benefits through a Medicare Advantage plan, you do not need supplement insurance.
What is covered by Medicare Supplement Insurance?
Basically, Medicare supplement insurance helps pay the 20% of your health care costs that Original Medicare (Part A & B) does not cover. Here are some of the costs that plans may help with. Read More >
Can I enroll in a Medicare Supplement if I have a Medicare Advantage plan now?
It depends on your Health. You can always apply for a Medicare Supplement plan, but you are not guaranteed acceptance unless it is during your Initial Enrollment Period (7 month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65). Otherwise, you will most likely be subject to Medical underwriting. Which means the insurance company can deny you coverage if you are in poor health.
When can I change Medicare Supplement plans?
You can always change Medicare Supplement (Medigap) plans at any time of the year. There is no restriction on when you can change, however if you attempt to make a change without using the “birthday rule”, you will have to qualify medically. Which means you can be denied if you are in poor health! Under the “birthday rule”, you are always guaranteed acceptance even if your current health condition would normally disqualify you for coverage. Therefore, we strongly suggest reviewing your Medicare Supplement plan every year during your Birthday month. Since Medicare Supplement (Medigap) insurance involves private insurance companies, you will find this California law helps stimulate competition and often lower premium rates on Medicare Supplement policies. Basically, this is a great time to shop the market to see if there is any other Medicare Supplement (Medigap) plans that are more affordable than what you currently have.
What is covered by Medicare Advantage Insurance?
By law, Medicare Advantage plans must provide at least the same coverage that’s offered by Original Medicare Parts A and B. Beyond what’s required, plans may include a variety of benefits. In general, Medicare Advantage plans help pay for the following services. Read More >
What are the different types of Medicare Advantage plans?
There are six Medicare Advantage (MA) plan types. The main differences between them are provider access and cost sharing. Coordinated care plans have stricter rules and generally cost you less. Other plan types have more flexibility and may cost more. Below are six different types of MA plans. Read More >
Medicare Part D (Prescription Drug)
What is a tiered formulary?