Beginning in 2014, many individuals and families will be eligible to receive subsidized coverage through Connect for Health Colorado if they are not eligible for Medicare, Medicaid or the Children’s Health Insurance Program and are not offered affordable coverage through their employer.
Here is Connect for Health Colorado’s Cost Calculator for Individuals and Families.
Notes: This calculator shows expected spending for families and individuals eligible to purchase coverage in the Exchange under the Affordable Care Act. Under the law, maximum contributions to premiums will be based on modified adjusted gross income, while estimates in this calculator are based on the annual income entered by the user. Actual premiums in the Exchange are not yet known. The premiums in this calculator reflect national estimates from the Congressional Budget Office for silver plans, adjusted for premium inflation and age rating.
Writing in the Colorado Statesman on March 8, 2013, Miller Hudson has done the best work I have seen so far in explaining why we are in the fix we are in with the high cost of healthcare, what affect the Affordable Care Act is likely to have and what some ideas about how it might all become workable in the future. I highly recommend you invest a few minutes in reading this article.
Here, Courtesy of the Colorado Department of insurance, is their “Glossary and Definitions” for health insurance. This information is provided by DORA so you can be familiar with some of the terms you may see in a health insurance policy. If you have questions, call the Division of Insurance for more information.
Certain products and services sold to consumers may appear to be health insurance but actually address very specific concerns. Be sure the product/service you are considering is health insurance, if that is what you want to buy.
– Does the word “insurance” appear in marketing materials?
– Does the health insurance carrier and/or the salesperson for the carrier appear in the Division of Insurance database as a licensed carrier and/or licensed insurance producer in Colorado?
An ”access fee” is a specific amount that a person covered under the policy must pay each time certain services are used or received. The access fee is not part of the deductible amount, and is not usually reimbursed by the health insurance carrier.
Catastrophic Health Insurance
Catastrophic health insurance is a type of health insurance that typically has very high deductibles. The coverage for a catastrophic policy does not kick in until you have paid your share of the deductible amount in the policy.
“High Deductible Health Plans (HDHPs)” are catastrophic health insurance policies created as a way to lower overall medical costs by providing a lower monthly premium in exchange for a higher annual health insurance deductible. With catastrophic health insurance plans, you pay for almost all medical care until you reach the annual deductible amount. If eligible, some people combine a high deductible health policy with a Health Savings Account (HSA). Read the policy carefully to understand what will be covered and how much your share of the costs will be if you need medical treatment.
After you have met the deductible for the covered period of time, your health policy may have a “co-insurance” that provides the patient will be responsible for a certain percentage of medical costs after the deductible has been met.
An individual health insurance policy may have a defined contestability period, so if the insured person becomes seriously ill during that time the health insurance carrier may check for any fraud or deception in the person’s application and medical history. This is intended to protect the carrier from individuals who may buy health insurance policies knowing they are in poor health and who may be misrepresenting themselves during the application process.
A “co-pay” is a fixed payment amount that is the responsibility of the patient. For example, a health policy may state that the patient must make a $25 co-pay for each doctor visit, and/or that the patient must pay $15 co-pay for each covered prescription medication that is purchased. (These amounts are examples, your policy may have different co-payment amounts.) The patient, or covered person, must make the required payment each time covered services are used. The amount of any required co-pays should be specified in the policy you select.
A deductible is a specific amount of money that you agree to pay before you receive any benefits for covered services from the health insurance carrier. Deductibles can vary, but if your policy has a $1,500 deductible, and you receive doctor’s care and medication that costs $1,200, you must pay for all of it. The carrier is not responsible for the amount of the covered service or medication you pay for up to the amount of deductible.
In addition to the monthly premium, or cost to be covered by insurance, you must also pay for all covered services until you reach the deductible amount. Generally, the higher the deductible is, the lower the monthly premium will be. If you agree to pay a $10,000 deductible, your premium would be lower, but if you are sick or injured, you will have to pay $10,000 worth of medicine and treatment before the carrier pays anything. (Check your policy to see what the options are.)
The entire deductible has to be met before your carrier will cover many of the services you could need, including hospital stays.
After you reach the deductible amount during a specific period of time, the carrier will begin reimbursing for covered medical services and treatment as specified in the policy. This may be at 100% co-insurance or could be another percentage, such as 50% of your medical treatment and services.
Once you meet your deductible then you’re done for that calendar year or for the period specified in your policy. The following year, or next deductible period, you have to start satisfying the deductible all over again.
Disclosure (of medical history and status)
When applying for individual health coverage, you will be asked to “disclose” any existing medical conditions, existing medications and past medical history. You must answer the questions truthfully. If the health insurance carrier learns that you have not provided all requested information about your health status, the policy may be cancelled and your coverage denied.
Discount Health Plan
A “discount health plan” refers to a type of “buyers’ club” that specifically markets reduced-rate health care services. The Plan typically charges a membership fee in exchange for a list of health care professionals who will provide services at a discounted rate to members of the Plan. Plans may be marketed to consumers as a way to save money on various health services, such as medical, dental and vision care, as well as pharmacy and/or chiropractic services.
Be aware that state laws protecting consumers of insurance will not protect people who buy Discount Health Plans. For example, health insurance laws that guarantee access to providers, do not apply to these plans. Discount Health Plans do not qualify as “creditable health insurance coverage.” This means that if you drop your health insurance after purchasing a Discount Health Plan and later decide to purchase health insurance again, your new insurance may not — and probably will not — cover pre-existing conditions for a period of time.
The Division of Insurance provides a guide to understanding Discount Health Plans.
If you have been diagnosed or treated for a previous condition, illness, or injury, before you were insured, the health insurance carrier may not want to cover continuing treatment for that medical condition. The carrier does not want people to wait to purchase insurance coverage until they know they will need treatment. When a condition is already known to the consumer, the carrier may offer health insurance that covers other conditions that arise, but excludes treatment for anything that was pre-existing before the insurance was purchased. Naming specific illnesses, injuries or conditions that are “exclusions” on the policy means that the carrier will not pay for any treatment associated with them. Some individual health policies may allow coverage for the pre-existing condition after a certain time period (usually 12 months) has passed with continuous health insurance coverage.
An exclusion in your policy may also mean refer to anything the health insurance carrier will not cover, ranging from a type of drug to alternative treatments to a type of surgery. These exclusions can vary from policy to policy. A hospital stay may list a number of exclusions, sometimes anything “extra” that is not a medical necessity – from watching a rental television to using a hospital phone to deluxe meals – may not be covered. Cosmetic or elective surgery is often excluded, unless it is done in response to a medical condition. Dental treatment and vision needs are usually excluded unless treatment is required due to an accident or illness. If dental and or vision treatments are covered, it should be spelled out in your policy.
An exclusionary rider is a part of your policy that states when there are certain conditions or types of illnesses that will NOT be covered by your policy. The exclusionary rider eliminates coverage for any medical treatment associated with the medical condition or previously diagnosed illness specified on the rider.
Health Savings Account (HSA)
A Health Savings Account is a type of savings product that offers a different way for consumers to pay for their health care. HSAs are designed to encourage individuals to save money they may need for future health care expenses on a tax-free basis.
To be able to take advantage of HSAs, you must be covered by a qualified High Deductible Health Plan (HDHP). Because an HDHP generally costs less than what traditional health care coverage costs, the money saved on insurance can be put into the Health Savings Account.
People can sign up for Health Savings Accounts with banks, credit unions, and insurance companies, and sometimes their employers. The IRS has more information on the tax benefits and consequences of HSAs.
Limited Benefit Health Insurance Policies
“Limited benefit health insurance policies” can cost far less than traditional insurance, but cap what health insurance carriers will pay toward medical care. For example, the policy may pay $2,500 per person, per year, an amount that would be exhausted by a single trip to the emergency room. Some limited benefit health insurance policies have daily caps, such as paying a few hundred dollars a day toward hospital coverage. This differs from traditional health insurance, which generally covers most medical expenses in a given year, after deductibles and co-payments have been made.
Before purchasing a “limited benefit health insurance policy”, find out if you will be covered for hospital visits or routine doctor’s care and make sure you understand the all of the limits in the benefits provided.
Major Medical Health Insurance
Major Medical health insurance policies typically provide comprehensive coverage for hospital, doctor, x-ray and laboratory expenses.
Mandated Health Benefit
Mandated health benefits are benefits that are required to be covered by law. There are both federal and state mandated benefits. In Colorado (as in many states), the mandated health benefits may not apply to all types of health insurance policies or plans offered in the state. Some mandated health benefits are required of group health plans, but not of individual policies. If you have previously been covered by a group health plan, and are now shopping for individual health insurance, check carefully to see what the new policy covers. Many people assume that individual policies will have the same health mandates, and they may not. Covering some of these health mandates is optional for individual health policies.
There are some mandated benefits that are required by federal law, and there are some that are required by state law. Colorado statutes may mandate some benefits for certain types of insurance (benefits that must be covered by group plans, for example), that are not mandated for all types of insurance (such as individual coverage.)
If you have experienced an illness or disability for which you have been diagnosed, treated or advised, that is considered a “pre-existing condition.” When you apply for an individual health insurance policy, you will be asked to describe any pre-existing conditions or previous treatment. The health insurance carrier may decide to offer you health coverage with an “exclusion” for the specific condition, even if you are not currently experiencing problems. This means the carrier will not cover any medical treatment for the excluded condition. Failing to mention a pre-existing condition for which you have previously sought medical advice is a reason for the carrier to rescind or cancel your policy at a later date. It is always advisable to provide a full and complete medical history.
The amount paid to the health insurance carrier each month to purchase health coverage. The premium is paid by the policyholder on an individual policy. On employer group plans, the cost of the premium amount can be shared by the employee and the employer.
Reasonable and Customary Charges (also called “Usual, Customary and Reasonable” or UCR)
The cost associated with a health care service that is consistent with the going rate for identical or similar services within a particular geographic area.
Reimbursement for out-of-network providers is often set at a percentage of the “usual, customary and reasonable” charge, which may differ from what the provider actually charges for a service.
When an insurer disallows a portion of a charge as being in excess of the Usual and Customary allowance, it means only that the charge is in excess of the standard the company used to determine Usual and Customary, or UCR. Providers are free to charge whatever fee for service they choose. Your insurance coverage is designed to provide benefits up to the plan’s Usual and Customary percentile and is priced accordingly.
Your policy should contain a definition of Reasonable and Customary (or UCR) and explain how claims will be paid. If you disagree with the amount paid or if you believe a claim was denied improperly, there is a step-by-step process by which consumers may appeal the decision.
If you have questions or complaints about your insurance, please contact the Colorado Division of Insurance for assistance.
As is now the case with Social Security, we older folks will continue to depend on younger people to pay more to maintain our standard of living. Now the younger generations will be subsidizing our health insurance. See the article below published February 22, 2013.
By David Morgan
WASHINGTON (Reuters) – The Obama administration on Friday finalized new consumer safeguards for health insurance that impose tighter restrictions on what insurers can charge older customers, despite industry warnings that the young may be forced to pay more as a result.
The Department of Health and Human Services rejected an industry request to phase in a reform prohibiting insurers from charging older beneficiaries premiums more than three times higher than those available to younger adults.
The so-called 3:1 ratio, due to take effect in 2014 in the individual and small-group markets, is a cornerstone of consumer safeguards enshrined in the 2010 Patient Protection and Affordable Care Act. The law also bars insurers from policies that discriminate on the basis of gender and pre-existing conditions.
Health insurers, which often charge adults over age 50 far higher rates, had asked HHS to start out with a 5:1 ratio in 2014 and move gradually to the tighter 3:1 ratio over a number of years, saying too abrupt a change would cause rates for younger beneficiaries to skyrocket.
“The new restrictions on age rating will result in an overnight increase in health care costs for people in their 20s, 30s, and early 40s,” said Karen Ignagni, president of America’s Health Insurance Plans, an insurance trade association.
She and other industry executives have warned that higher costs could encourage young adults to forego coverage and thus deny the industry the younger, healthier customers that were supposed to keep costs down as the health insurance market implements President Barack Obama’s reform law.
The law imposes a financial penalty on most adults who fail to obtain coverage by January 1, 2014. But industry officials have complained that the fine may be too small to alter behavior, particularly if costs rise sharply.
“This increases the likelihood that younger, healthier people forgo purchasing insurance until they are sick or injured. When this happens, costs go up for everyone, young and old,” Ignagni said.
AHIP said people in their 20s and 30s could see insurance premiums jump 29 percent and 19 percent, respectively, while adults aged 50 to 64 receive reductions of between 5 percent and 8 percent.
The administration said in the 145-page regulation that its hands were tied by the healthcare law.
“We do not have the legal authority to permit any rating factors in the final rule other than those explicitly permitted (by the law),” HHS said. “Further, we do not have the legal authority to provide for a phase-in.”
U.S. officials contend that any pressure for higher rates would be mitigated by greater competition and federal subsidies that will be available for working families in the form of premium tax credits.
Consumer groups including AARP, the powerful lobbying group for older Americans, welcomed the decision.
“Implementing a limited use of age rating immediately thwarts what would have been a negative and disproportionate effect on Americans aged 50 To 64,” said AARP Executive Vice President Nancy LeaMond.
The Affordable Care Act, nicknamed “Obamacare,” is expected to provide health coverage for an estimated 38 million people after 2014. Most are expected to obtain subsidized private insurance via new online state healthcare marketplaces that are scheduled to start enrolling beneficiaries on October 1.
The administration is also working with half of the 50 U.S. states to extend the Medicaid program for the poor to cover adults living near the federal poverty level.
Aside from age, the law still allows insurers to vary premiums based on tobacco use, family size and geography. Other forms of discrimination based on gender, past insurance claims, occupation or the size of a small employer will not be permitted from 2014.
(Additional reporting by Caroline Humer; Editing by Ros Krasny and Dan Grebler)
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In my opinion, the single most important factor in the ever increasing cost of medical care is clients’ inability to obtain competitive pricing for medical treatments and their lack of knowledge/confidence in choosing the best option. Is the knee MRI offered by one provider for $297 really as good as the same test offered by someone else at $1261?
According to an article published November 2, 2012 in the Denver Post, the new Colorado All Payer Claims Database will shine a harsh spotlight on health price differences that can not be justified.
Organizers claim the database will be Colorado’s most accurate reflection ever of costs actually paid by consumers, insurance companies and government plans. Many other listings have focused on “charges” — the retail prices for health care rarely paid by large insurers or the very poor.
By late next year, another leap in data will allow consumers and analysts to compare actual costs for various services on a hospital-by-hospital or doctor-by-doctor level, with the provider named and open to questioning.
Cost experts estimate $750 billion, or about 25 percent, of U.S. health care spending is unnecessary and driven by waste, misuse or overuse. That waste won’t be cut until consumers can shop accurately for health care, and providers can see how others deliver care more efficiently, database promoters said.
By late 2013 or early 2014, consumers should be able to use an interface showing, for example, their share of cost and the insurer’s share for a colonoscopy at specific hospitals within a 20-mile radius. A side-by-side column would also show a quality rating for each facility, taking into account factors like how many post-surgery infections occurred at that hospital.
I believe that if this new database can live up to these projections, it will have a huge impact on lowering medical cost.
Dr. Don SchmidtCanyon Chiropractic Center - Boulder, Colorado
Thank you for saving us money on our health insurance! We really appreciated your willingness to 'hand hold' us through the process. It can be a daunting task to choose from all the available insurance plans out there. You made it almost easy!
Don MartingMartin Auctioneering - Longmont, Colorado
I can't thank you enough for helping me and saving me a significant amount of money. I truly believe that you had my best interest at heart.