Individual & Family Health Insurance

When you buy health insurance, you pay for your plan. In return, your plan will pay for numerous health care costs on your behalf. Given the astronomical costs of care today, this is a benefit that none of us can afford to be without.

Both federal and state health care laws, including the Affordable Care Act, govern how health insurance plans offer benefits and structure costs. There are numerous types of plans on the market, including:

• HMOs
• PPOs
• Point-of-Service (POS) Plans
• Fee-for-Service Plans
• Health Savings Accounts (HSAs)

Other, more specialized plans include:

• Dental Coverage
• Vision Coverage
• Long-Term Care Insurance
• Temporary Health Insurance
• Supplemental Insurance
• Disability Insurance
• Child Health Insurance
• Travel Health Insurance
• Prescription Drug Insurance

Additionally, Medicare participants might qualify for a variety of specialized, private plans, such as:

• Medicare Advantage (Part C) Coverage
• Medicare Prescription Drug (Part D) Plans
• Medicare Supplements (Medigap plans)

The plan options that you choose might be totally different than those of your friends and neighbors. After all, your medical needs are unique, and you have different priorities and intended uses for your plan. With the help of your agent, you can make sure you have the benefits you need.

There are essentially two kinds of heath insurance: Fee-for-Service and Managed Care. Although these plans differ, they both cover an array of medical, surgical and hospital expenses. Most cover prescription drugs and some also offer dental coverage.

1. Fee-For-Service
   These plans generally assume that the medical professional will be paid a fee for each service provided to the patient. Patients are seen by a doctor of their choice and the claim is filed by either the medical provider or the patient.
2. Managed Care
   More than half of all Americans have some kind of managed-care plan. Various plans work differently and can include: health maintenance organizations (HMOs), preferred provider organizations (PPOs) and point-of-service (POS) plans. These plans provide comprehensive health services to their members and offer financial incentives to patients who use the providers in the plan.

Different health insurance plans cover different services. General individual health insurance plans can cover a myriad of services, such as:

• Standard checkups & physician fees
• Inpatient & outpatient surgical procedures
• Hospitalization costs
• Emergency care
• Ambulance services
• Equipment and assistive devices like diabetic testing items, wheelchairs and more
• Diagnostic testing like labs or x-rays
• Preventive services like vaccinations, diet counseling or cholesterol monitoring
• Certain nursing home or rehab facility costs

Specialty plans like dental, vision or prescription drug policies will pay for those services alone.

Still, because all plans differ, factors like the care you can receive, where you can receive it, and how much it is going to cost you will vary. Let our agents guide you in the right direction to make sure you have the coverage you need.

Every private health insurance plan contains its own cost-sharing requirements. This obligates the policyholder to pay for a portion of their health care themselves while the insurer covers the rest.

• Most health plans have coverage networks, which are the groups of physicians and facilities that will accept your plan as a form of payment. When you use an in-network provider, your plan will pay for your care to its fullest extent. Visiting an out-of-network provider will likely cost you more money and some out-of-network care won’t have coverage at all.
• Certain care, namely preventive care, might come at no cost to the policyholder.
• Many plans include deductibles. A deductible is the cost that you must pay for your own care before your insurer pays for your care. However, many plans waive deductibles for certain care.
• Most plans have coinsurance requirements. Under a coinsurance rule, your insurer pays for a percentage of your care cost, and you pay the rest. For example, on an 80/20 coinsurance plan your insurer pays 80% of a medical bill and you pay 20%. Coinsurance might not apply to all services, however.
• Care services might also include copayments. A copayment is a fee that you pay at the time of receiving care, or shortly afterwards. For example, your plan might require you to pay a $30 copayment for a regular checkup while a specialist copayment might be $50.

Numerous factors can influence health insurance premiums, including your qualifications for cost assistance on certain plans. If you choose a plan through the Covered California marketplace, then you might be able to receive lower premiums or tax incentives, depending on your income or other factors.

We fully understand how complicated it might seem to get health insurance in a constantly changing marketplace. And that’s why we’re here to help you navigate the myriad of plans, subsidies, and specialty coverage options out there to find the benefits that are perfect for you. Our job is to make it easy for you to understand both the coverage you need and how you can get it effectively.

Because of old age, mental or physical illness, or injury, some people find themselves in need of help with eating, bathing, dressing, toileting or continence, and/or transferring (e.g., getting out of a chair or out of bed). These six actions are called Activities of Daily Living–sometimes referred to as ADLs. In general, if you can’t do two or more of these activities, or if you have a cognitive impairment, you are said to need “long-term care.”

Long-term care isn’t a very helpful name for this type of situation because, for one thing, it might not last for a long time. Some people who need ADL services might need them only for a few months or less.

Many people think that long-term care is provided exclusively in a nursing home. It can be, but it can also be provided in an adult daycare center, an assisted living facility, or at home.

Assistance with ADLs, called “custodial care,” may be provided in the same place as (and therefore is sometimes confused with) “skilled care.” Skilled care means medical, nursing, or rehabilitative services, including help taking medicine, undergoing testing (e.g. blood pressure), or other similar services. This distinction is important because Medicare and most private health insurance pays only for skilled care–not custodial care.

What Are The Types Of Disability Insurance?

There Are two types of disability policies: Short-Term Disability (STD) and Long-Term Disability (LTD):

1. Short-Term Disability policies (STD) have a waiting period of 0 to 14 days with a maximum benefit period of no longer than two years.
2. Long-Term Disability policies (LTD) have a waiting period of several weeks to several months with a maximum benefit period ranging from a few years to the rest of your life.

Disability policies have two different protection features that are important to understand.

1. Non-Cancelable means the policy cannot be canceled by the insurance company, except for nonpayment of premiums. This gives you the right to renew the policy every year without an increase in the premium or a reduction in benefits.
2. Guaranteed Renewable gives you the right to renew the policy with the same benefits and not have the policy canceled by the company. However, your insurer has the right to increase your premiums as long as it does so for all other policyholders in the same rating class as you.

In addition to the traditional disability policies, there are several options you should consider when purchasing a policy:

• Additional Purchase Options
  Your insurance company gives you the right to buy additional insurance at a later time.
• Coordination Of Benefits
  The amount of benefits you receive from your insurance company is dependent on other benefits you receive because of your disability. Your policy specifies a target amount you will receive from all the policies combined, so this policy will make up the difference not paid by other policies.
• Cost Of Living Adjustment (COLA)
  The COLA increases your disability benefits over time based on the increased cost of living measured by the Consumer Price Index. You will pay a higher premium if you select the COLA.
• Residual Or Partial Disability Rider
  This provision allows you to return to work part-time, collect part of your salary and receive a partial disability payment if you are still partially disabled.
• Return Of Premium
  This provision requires the insurance company to refund part of your premium if no claims are made for a specific period of time declared in the policy.
• Waiver Of Premium Provision
  This clause means that you do not have to pay premiums on the policy after you’re disabled for 90 days.