Health insurance is coverage that provides for the payments of benefits as a result of sickness or injury. Includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment.

HEALTH INSURANCE TYPES

1. Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs)

• • HMOs and EPOs may limit coverage to providers inside their networks. A network is a list of doctors, hospitals, and other health care providers that provide medical care to members of a specific health plan. If you use a doctor or facility that isn’t in the HMO’s network, you may have to pay the full cost of the services provided.
  • HMO members usually have a primary care doctor and must get referrals to see specialists. This is generally not true for EPOs.

2. Preferred Provider Organizations (PPOs) and Point-of-Service plans (POS)

• • These insurance plans give you a choice of getting care within or outside of a provider network. With PPO or POS plans, you may use out-of-network providers and facilities, but you’ll have to pay more than if you use in-network ones. If you have a PPO plan, you can visit any doctor without a referral.
  • If you have a POS plan, you can visit any in-network provider without a referral, but you’ll need one to visit a provider out-of-network.

3. High Deductible Health Plan (HDHP)

• • High Deductible Health Plans typically feature lower premiums and higher deductibles than traditional insurance plans. 
  • If you have an HDHP, you can use a health savings account or a health reimbursement arrangement to pay for qualified out-of-pocket medical costs. This can lower the amount of federal tax you owe.

4. Catastrophic Health Insurance Plan

• • A catastrophic health insurance plan covers essential health benefits but has a very high deductible. This means it provides a kind of “safety net” coverage in case you have an accident or serious illness. 
  • Catastrophic plans usually do not provide coverage for services like prescription drugs or shots. 
  • Premiums for catastrophic plans may be lower than traditional health insurance plans, but deductibles are usually much higher.

What is Group Health Insurance?

Group Policies are purchased by your employer or an association. The policy is issued in the group name and Certificates of Coverage are issued to group members (employees). Family members or dependents on your policy  and your employer may require you to pay for some or all of the monthly premium. 

Advantages of Group Health plan:

1. No medical underwriting to enroll employees or your dependent souses or children.
2. 12 months rate guarantee, will only change if you add or delete employees from the plan will plan change.
   
3. Mix and Match Group Carriers (ie: some employees want Kaiser while others want PPO, their own doctors).
   
4. New industry association health discount. If you are part of certain industries (ie: engineering and restaurant) may be eligible to 30% discounts. 
   
5. HSA combines a high deductible plan with the ability to fund HSA tax accounts for first dollar coverage.
   
6. If certain requirements are met, may qualify for tax subsidies. (Average salary under $50K – not including owners. Up to 25 employees)
   
7. Guaranteed renewal. No pre-existing condition or sudden illness will change the renewal coverage.
   
8. Eligible Small Employer. Federal and state laws require that employer have:

• • at least 1 but not more than 100 employees to qualify as a small business group health insurance. 
  • employed a non – owner W2 employee at least 50% of the preceding calendar year or 50% of the preceding quarter.
  • submit most recent Quaterly Wage Statement (form DEC) to insurance company at time of applying for coverage. The statement is used as a roster of employees to determine eligibility. 
  • Employee must be a “W2” employee.
  • Employee must average 30 hours or more per week of a month.
  • 75% of eligible employees must go with the plan
  • The company must pay at least 50% of the employee premium

10 Minimum Essential Benefits Requirements:

All small businesses that offer health care coverage to employees must have these benefits included:

1. Outpatient care you receive in a doctor’s office and not in the hospital
2. Evaluation and treatment in the emergency room
3. Inpatient care after you’ve been admitted to a hospital
4. Care before and after your baby is born
5. Treatment that includes psychotherapy and counseling for mental health and substance use
6. Prescription medicine
7. Physical and occupational therapy, speech-language pathology, psychiatric rehabilitation and other services to help you recover from an injury, disability or chronic condtion 
8. Laboratory tests

There are multiple types of Health Insurance coverages available in California:

1. Short Term:  low cost plans. Good for between jobs; waiting for other coverage to begin; waiting t be eligible for Medicare coverage; with out health insurance, outside Open Enrollment period. Covers for period of 30days to 12 months. Covers services and treatments related to unexpected illness and injury, such as outpatient  visits to the doctor, emergency room visits, hospital stays, surgeries and related x-rays and lab services.

    

2. Medicaid and the Children’s Health Insurance Program (CHIP):  federal – state plans for low income eligibility.

    

3. Medicare: federal health plan for people who are 65 or older, people with disabilities, and people with end stage renal disease.

    

4. Student: stay on parent’s health plan till age 26 or stay on school sponsored plan. You may lose coverage if you become part-time student or transfer schools.

    

5. COBRA: offered by employers for the continuation of group insurance benefits for short amount of time if employee was fired or quit work.

    

6. Covered CA: state’s health insurance marketplace, also called an exchange. Currently there are 12 carriers – 

• • Anthem Blue Cross
  • Blue Shield of California
  • Chinese Community Health Plan
  • Health Net
  • Kaiser Permanente
  • L.A. Care Health Plan
  • Molina Healthcare
  • SHARP Health Plan
  • Oscar Health
  • Valley Health Plan
  • Western Health Advantage
  • Medi-Cal

Having the right coverage is very important in every family. It can literaly be a life or death situation. We’ll make sure your family is properly covered with health insurance premiums you can afford. 

Health care expenses are a big concern for especially retirees on  a fixed income. Medicare Supplement insurance plan cam help you pay for medical costs that Medicare may not be able to cover.  

What is Medicare?

Medicare is a federal health insurance program for:

• People age 65 or older
• People with certain disabilities
• People with End-Stage Renal Disease

ENROLLMENT PERIOD

MEDICARE HAS 4 PARTS:

Part A   (Hospital Insurance)

INPATIENT HOSPITAL CARE

• Hospital stays
• Home health services (following an acute stay)
• Hospice care
• Skilled nursing care
• Transplants

Part B   (Medical Insurance)

DOCTOR & OUTPATIENT VISITS

• Doctor visits
• Home health services (not following an acute stay)
• Ambulance services
• Outpatient physical, speech, and occupational therapy
• Outpatient surgeries
• Durable medical equipment
• X-rays

Part C   (Medicare Advantage)

COVERS SAME BENEFITS AS PART & B

May include additional coverage for:

• Prescription drug coverage
• Dental, vision, and hearing services
• Health and wellness programs

Offered through private insurance companie

Part D   (Rx Drug Coverage)

• Each plan offers its formulary
• Costs vary based on brand vs. generic medications
• Costs vary based on drug tiers

Offered through private insurance companies

Medicare Supplement (Medigap) insurance can also help pay some of the health care costs that original Medicare does not cover like:

• Copayments
• Coinsurance
• Deductibles

Offered through private insurance companies

Medigap excludes: long-term care, vision, dental care, hearing aids, eyeglasses or private -duty nursing. 

covered health care costs. Then your Medicare supplement insurance policy pays its share.

A Medigap policy is different from a Medicare Advantage Plan. Those plans are ways to get Medicare benefits, while a Medigap policy only supplements your Original Medicare benefits.

Important Things to Know About Medicare Supplement Coverage

• If you have a Medicare Advantage Plan, you can apply for a Medigap policy, but make sure you can leave the Medicare Advantage Plan before your Medigap policy begins.
• You pay the private insurance carrier a monthly premium for your Medigap policy in addition to the monthly Part B premium that you pay to Medicare.
• A Medigap policy covers one person. If you and your spouse both want Medigap coverage, we’ll work with you to setup two separate policies.
• Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company can’t cancel your Medigap policy as long as you pay the premium.