Health Insurance Domain

Document
on
Health Insurance
Health Insurance Coverage
Health insurance policies are contracts between you and a health insurance company. A list of benefits that are covered
by the policy will be provided with your health insurance policy. Benefits could include medication, treatment, testing, or
other medical care. The benefits that are covered by the health insurance are known as covered services.
Major Medical Insurance Coverage
This type of health insurance coverage protects you from severe illness or injuries. The policy is normally extremely
broad with a high dollar amount for maximum benefits.
The following items are often covered by major medical insurance policies
!ab services
"#$ays
%iagnostic tests including &$'s and (AT#scans
Ambulance services
$adiology
Blood )and plasma*
+xygen
'ntensive care and other hospitali,ation )including all supplies and services including surgery*
&edication )prescription and other*
-ursing services and other medical services )including in#home care*
.hysicians services )surgical, medical, and diagnostic*
Anesthesia
%ental treatment for injuries
.rosthetics
How Health Insurance Works
Private health insurance helps people make sure they will be provided access to health care. Insurance also gives health
care companies assurance that their patients can afford the services and the bill will be paid in a reasonable amount of time.
Health insurance protects consumers from the potentially extreme cost of medical care. If you become extremely ill, the cost
can be financially overwhelming. Health insurance helps make sure that doesn't happen to you. Health insurance makes
health care more affordable, predictable, and manageable since the risk of expensive health care needs is pooled across a
large group of people.
Many of us cannot afford the risk of not having health coverage. Health insurance is costly, but the expense from even a
minor incident or illness can easily deplete your savings and can even leave you financially ruined.
Who Provides Health Insurance? Licensed Health Insurance Providers
oth publicly traded health insurance companies !owned by stockholders" and mutual health insurance companies !owned
by the policyholders" are licensed health insurers. lue #ross and lue $hield companies are also state licensed insurers.
%hese programs began as non&profit organi'ations under state hospital !lue #ross" and state medical !lue $hield"
organi'ations. lue #ross lue $hield organi'ations are now !with few exceptions" normal commercial health insurance
companies using the lue #ross lue $hield name.
Health Insurance Companies
Below is a comprehensive list of the health insurance companies operating in each state.
Alaska
(eltic 'nsurance (ompany
/olden $ule
Alabama
0ortis
/olden $ule
Arkansas
/olden $ule
American &edical 1ecurity !ife 'nsurance (ompany
Arkansas Blue (ross and Blue 1hield
Arizona
Health -et of Ari,ona
/olden $ule
.acifi(are of Ari,ona
0ortis
Humana
Aetna
('/-A
California
Blue 1hield of (alifornia
Blue (ross of (alifornia
.acifi(are
Health -et
2aiser .ermanente of (A
0ortis
Aetna
Colorado
2aiser .ermanente
Anthem Blue(ross Blue1hield
/olden $ule
.acifi(are
Humana
Connecticut
/olden $ule
Anthem Blue (ross and Blue 1hield of (T
Aetna
District of Columbia
(are0irst Blue(ross Blue1hield
Aetna
0ortis
2aiser .ermanente
Delaware
/olden $ule
Aetna
Florida
/olden $ule
0ortis
3ista Healthplan of 1outh 0lorida
Humana
eorgia
2aiser .ermanente
/olden $ule
Blue (ross Blue 1hield of /eorgia
Humana
0ortis
Aetna
Hawaii
2aiser .ermanente of H'
Iowa
/olden $ule
Idaho
Blue (ross of 'daho
0ortis
$egence Blue1hield
Illinois
4-'(A$5
/olden $ule
Blue(ross Blue1hield of 'llinois
Humana
0ortis
Aetna
Indiana
Anthem Blue (ross and Blue 1hield
4-'(A$5
/olden $ule
!ansas
Blue(ross Blue1hield of 2ansas (ity
Humana
!entuck"
Humana
#ouisiana
0ortis
Humana
Blue(ross Blue1hield of !ouisiana
Mar"land
/olden $ule
Aetna
2aiser .ermanente
Michigan
/olden $ule
0ortis
Blue (ross Blue 1hield of &ichigan
Humana
Minnesota
Blue (ross and Blue 1hield of &innesota
Health.artners
&edica of &innesota
Missouri
Blue(ross Blue1hield of &issouri
/olden $ule
Blue(ross Blue1hield of 2ansas (ity
Humana
Mississippi
/olden $ule
Montana
0ortis
$orth Carolina
0ortis
$orth Dakota
0ortis
$ebraska
Blue(ross Blue1hield of -ebraska
/olden $ule
$ew Hampshire
$ew %erse"
Hori,on Blue (ross Blue 1hield of -ew 6ersey
+xford Health .lans, 'nc.
$ew Me&ico
Blue (ross Blue 1hield of -ew &exico
$evada
Anthem Blue(ross Blue1hield
Health .lan of -evada
4-'(A$5
.acifi(are of -evada
$ew 'ork
/roup Health 'ncorporated
(hio
4-'(A$5
/olden $ule
2aiser .ermanente of +hio
&edical &utual
Humana
0ortis
Aetna
(klahoma
/olden $ule
(regon
$egence Blue(ross Blue1hield of +regon
Health -et of +regon
!ife7ise Health .lan of +regon
2aiser .ermanente
.acifi(are of +regon
)enns"lvania
/olden $ule
0ortis
Aetna
*outh Carolina
Blue (ross and Blue 1hield of 1outh (arolina
/olden $ule
*outh Dakota
+ennessee
/olden $ule
Blue(ross Blue1hield of Tennessee
Humana
+e&as
4-'(A$5
/olden $ule
0ortis
Blue(ross Blue1hield of Texas
Humana
Aetna !ife 'nsurance (ompany
,tah
'ntermountain Health (are
$egence Blue(ross Blue1hield of 4tah
-irginia
/olden $ule
Trigon Blue (ross Blue 1hield
4-'(A$5
Anthem Blue (ross and Blue 1hield of 3A
Aetna
2aiser .ermanente
.ashington
!ife7ise Health .lan of 7ashington
/roup Health (ooperative
$egence Blue1hield
$egence Blue(ross Blue1hield of +regon
Asuris -orthwest Health
.isconsin
/olden $ule
Blue (ross Blue 1hield of 7isconsin
Humana
."oming
0ortis
/lue Cross /lue *hield Health Insurance
Blue (ross Blue 1hield Association is a company composed of many independent health insurance companies
throughout every state in the nation as well as .uerto $ico, 6amaica, .anama, and 4ruguay. These companies are
independent franchises that address the health needs of each particular area )usually a state or territory* for which they
were designed.
1ome companies use only the name Blue (ross Association and others use only the name Blue 1hield Association, but
most independent companies are part of the Blue (ross Blue 1hield Association. Blue (ross and Blue 1hield is America8s
oldest and largest independent health insurer. However, the company actually arose from two simultaneous, but
separate solutions for the health care of workers8 organi,ations.
+he Histor" of /lue Cross /lue *hield
The B(B1 Association began in 9:;:, when 6ustin 0ord 2imball, the new vice president of Baylor 4niversity in %allas,
Texas, developed a health plan that guaranteed teachers ;9 days of hospital care for <= per year. 1oon the plan was
extended to other employee groups in %allas, and similar plans began to spread nationally. He called his new
organi,ation Hospital 1ervice Association. The Blue (ross symbol was first used to represent the new company in 9:>?
indicating hospital care for its members. 'n 9:>:, a (hicago#based organi,ation, American Hospital Association, began
using the Blue (ross symbol to signify that certain standards were being maintained across the country. 'n 9:=@, the
two organi,ations merged under the name the Blue (ross Association. The two organi,ations remained affiliated until
9:A;.
'n 9:9A, in the .acific -orthwest, particularly in the mining and lumber camps, an organi,ation known as .ierce (ounty
&edical Bureau of Tacoma, 7ashington )now known as $egence Blue 1hield* was founded. The concept behind this plan
was that members would pay monthly fees to a medical service bureau composed of groups of physicians. The idea
Buickly spread, and in 9:>:, (arl &et,ger in Buffalo, -ew Cork created the D1hield 1ymbolE. The shield represented the
group of doctors who were participating in the medical care program. 4sing the shield symbol, the first official Blue
1hield plan was founded in (alifornia in 9:>:. At that time, it was called the Associated &edical (are .lans, but was
soon changed to the -ational Association of Blue 1hield plans.
7hile traditionally, Blue (ross was used for hospital coverage and Blue 1hield was used for medical )or doctor and care
giver* coverage, the two companies merged in 9:F;, after years of a mutually enforcing, but often competitive
coexistence. The Blue (ross Blue 1hield Association is now a network of independent, locally operated insurance
companies that together insure about one in every four Americans. The B(B1 Association encompasses the full
spectrum of health care services including .referred .rovider +rgani,ations )..+*, Health &aintenance +rgani,ations
)H&+*, .rescription &edication 1ervices, &edicare 1upplemental (overage, and &edicare .art % ).rescription Assistance
.rograms*. 1ome states provide %ental (are and 3ision (are .rograms.
/lue Cross /lue *hield Companies
Almost every state has community#based programs, many of which are free, to aid in health improvement and
maintenance. &any states have incorporated programs that are free to all schools to assist in dealing with the
increasing problem of childhood obesity. &any states also offer free, or low cost medical help, such as
immuni,ations for medically underserved children. Almost all states offer specific programs for prevention and care
for medical problems that are uniBue to their particular areas.
Types of Health Insurance(
Managed #are Health Plans
HM) Health Plans
PP) Health Plans
Point&of&$ervice !P)$" Plans
*ision Insurance
Individual Health Insurance
+amily Health Insurance
Additional Topics
#),- Health Insurance
Health Insurance for Seniors
Medicare
Medicaid for $eniors
Medicare $upplements
Managed are Plans
Managed care health insurance provides members with health care services at the lowest cost possible. Most managed
care plans also focus on prevention and healthy living in order to avoid health care costs altogether.

#urrently, nearly all health insurance plans available to consumers are managed care insurance plans. y specifying a
network of health care providers, managed care plans permit insurers to influence the treatment options of their clients.
Included in this category are Health Maintenance )rgani'ations !HM)", Preferred Provider )rgani'ations !PP)", and Point
of $ervice !P)$" plans.
Individuals covered by a HM) plan must get prior approval from their primary care doctor before getting any type of
speciali'ed treatment.
HM( )lans 0Health Maintenance (rganizations1
HMO plans are a kind of managed care health insurance plan. HMO plans have a contract with doctors and other health
care providers and they are directly involved in the medical treatment of their customers.
7hile HMO plans are generally the cheapest kind of health insurance coverage available, they are also the most
restrictive. These usually have a deductible but no coinsurance reBuirement.
&ost HMO plans reBuire that a primary care physician ).(.* be designated by recipients. That physician is the gateway
to all health care providers. 'f a HMO customer tries to visit a medical practitioner with no a referral from the .(., the
visit or treatment will not be paid for by the HMO health insurance plan.
Cour .(. and all referrals must be members of the network that the HMO plan has contracted with to provide services.
HMO plans and ..+ plans use management controls such as the .(. limitation and a focus on preventative care to
lower the cost of healthcare.
HMO plan members pay a monthly premium regardless of their medical needs. 'n return for the premium, HMO plans
provide various medical services, from checkups to surgery. &edical services are normally only paid for if the person
uses a provider in the HMO network and goes through their .(.. -etwork si,es vary widely, so be sure to check the list
of health care providers in your area.
Advantages of HM( )lans Disadvantages of HM( )lans
)reventative Care
HMO plans encourage members to seek medical treatment early
and to have annual checkups. They are focused on wellness and
many HMOs offer information to their members about staying
healthy.
)rimar" Care )h"sician atewa"
1peciali,ed medical attention can be more difficult to
obtain with an HMO plan. The .(. is the access to all
health care services you canGt see a specialist
without a referral. This helps the health insurance
company reduce expenses for its HMO members and
the company.
#east 2&pensive Health Insurance
There is usually not a coinsurance reBuirement with HMO plans.
'nstead of a deductible, most HMO plans have small co#
payments for medical services and treatments. 1o, regardless of
your medical needs, a HMO plan will probably just charge you
the monthly premium and a small co#payment.
$o Coverage for (ut3of3$etwork
HMO insurance will probably not cover a visit to a
doctor who is not in the HMO network, even if there
are no network providers in the area.
$o #ifetime Ma&imum )a"out
4nlike other health insurance plans, many HMO policies do not
have a lifetime maximum payout. They will pay for your medical
needs as long as you are a member.
*trict definitions
The definitions for HMO plans tend to be limited. 0or
example, an emergency room visit may only be
covered if it meets the companyGs definition of an
emergency, which could be surprisingly restrictive.
#ess complicated billing
Billing systems for HMOs are usually less complex than other
programs, so customers experience less problems.
More difficult to change doctors
&any HMOs discourage you from changing primary
care physicians. Cou may be limited to changing your
primary care doctor once or twice.
)atient 4uotas
.hysicians who participate in HMOs are often
reBuired to see a minimum number of patients every
day. This could limit the time your doctor can spend
addressing your needs. 1ome doctors receive a
particular amount from a HMO plan regardless of the
number of patients they see, making it preferable for
the doctor to have less appointments.
+ests
&any HMOs reBuire that diagnostic tests be
approved before they will be paid for. This could
delay your health care treatment.
))( )lans 0)referred )rovider (rganizations1
As managed care systems, PPO plans are very similar to H&+ plans. PPO plans provide health care for their members
by contracting with selected hospitals and doctors. &any PPO programs will cover non#network providers if you pay a
larger co#payment or deductible.
.hat is ))( Health Insurance5
A ))( is a roup of Doctors
%octors within the PPO network only provide care to a specific group. The PPO may be sponsored by a health insurance
company, an employer, or a group of employers. The health insurance group trades the increased patient number for a
discounted rate from the health care provider.
))( )lans are 6eimbursement )rograms
7ith a PPO health insurance plan, you will probably pay for your health care services and be reimbursed by the health
insurance company. +ften the doctor will send the bill to the health insurance company for you. The reimbursement that
you or you doctor get will depend on the policyGs co#payment and deductible, which are subtracted.
Advantages of ))( )lans Disadvantages of ))( )lans
Choice of doctor
PPO networks tend to be much bigger than H&+ networks.
'f you do see a non#network provider, the majority of PPO
plans will still cover a portion of the cost )it will be less than
they would pay for an in#network provider*.
More 2&pensive than HM(s
PPO plans are generally more expensive than H&+ health
insurance plans as a result of the flexibility they offer.
$o )rimar" Care )h"sician atewa"
Cou probably will not have to designate a .(. or obtain
referrals before you can visit a specialist if you are a
member of a PPO.
More paperwork
PPOs often reBuire more paperwork than comparable H&+
plans. (ustomer service and billing problems are often
more freBuent with PPO plans as well.
/etter Coverage for Chronic Conditions and $on3
traditional Medicine
.eople with chronic conditions such as back pain, allergies,
and arthritis tend to be more satisfied with PPO plans. A
PPO could also cover non#traditional treatment such as
chiropractic care or acupuncture.
)oint3of3*ervice 0)(*1 )lans
Point-of-service plans are major health insurance plans that bring together characteristics of both H&+ plans and ..+
plans. They are more flexible than H&+s, but they do reBuire that you select a primary care physician ).(.*. The .(.
must make referrals in order for you to see any other health care providers.
!ike a ..+ plan, point-of-service plans normally cover a portion of charges from out#of#network providers, but it will be
less than if an in#network provider is chosen. POS health insurance companies will usually make an exception if your
.(. refers you to an out#of#network provider.
Point-of-service plans usually charge a small co#payment to visit an in#network doctor and most do not have a
deductible.
Advantages of )oint3of3*ervice )lans Disadvantages of )oint3of3*ervice )lans
Choice of Doctor
'f you see a non#network provider, most POS plans will still
pay a percentage of the cost )it will be less than they would
pay for an in#network provider unless you obtain a referral
from a .(.*.
)rimar" Care )h"sician atewa"
The .(. is the gateway to all health care services. Cou
wonGt get complete coverage for a specialist without a
referral. However, unlike an H&+ plan, the POS plan will
probably pay a portion of the cost even if you donGt obtain
a referral.
*mall Co3)a"ment7 no Deductible
The majority of point-of-service plans have small co#
payments for medical services and treatments instead of a
deductible. There is normally a deductible and bigger co#
payment for non#network care however.
More 2&pensive than HM(s
Point-of-service plans tend to be more expensive than
H&+s, but less expensive than ..+s.
C(/6A Health Insurance
'n 9:F= (ongress passed the (onsolidated +mnibus budget $econciliation Act )(+B$A* in order to provide continued
group health insurance coverage that might otherwise be terminated. (+B$A is not an insurance plan or company, it is
a law. (+B$A health insurance provides retirees, some former employees, spouses, and dependant children the right to
temporary health coverage at group rates under certain conditions.
Health insurance under (+B$A tends to be more expensive for participants than health insurance provided for active
employees since employers usually pay part of health insurance premiums. However, it is usually less expensive than
individual health insurance.
Details of C(/6A Insurance
(+B$A health insurance applies to plans in both private sector as well as those sponsored by state and local
governments, provided previous health plans in the prior year were maintained by twenty or more employees. /roup
health insurance plans are defined as plans utili,ed by employers in order to provide medical benefits for employees and
their dependants through insurance or otherwise.
(+B$A defines some of these alternative plans as trusts, health maintenance organi,ations, self#funded pay,
reimbursement, or a combination. (+B$A medical insurance benefits include
'npatient and outpatient hospital care
.hysician care
1urgery and other medical benefits
.rescription drugs
Any other medical benefits such as dental and vision care
4nder (+B$A, after termination of employment, you have sixty days after to decide whether or not to take advantage
of continued health insurance coverage. The employer will ask that you pay for the premium on the health insurance
plus a ;H surcharge. +btaining (+B$A health insurance allows you to continue using the same benefits as under the
previous employer8s health insurance plan. .eople under the program receive the same benefits as current employees
so if the employer8s medical insurance plan changes, so does the plan under (+B$A.
Cou should seriously consider continuing coverage under (+B$A health insurance if you
Have had recent health problems
Have recently acBuired a job and the new employer does not offer a health benefit plan
Are pregnant or planning to become pregnant
Have a history of medical problems
Are taking expensive medications
7ant guaranteed continual health care coverage, but at a higher cost
Have ongoing health problems
Have comprehensive benefits and don8t mind paying more for them
Have been declined recently for private insurance
Have had an accident within the =@ day enrollment window
(+B$A health insurance lasts a minimum of 9F months and a maximum of ;: months. After the original 9F months, it
may be extended if you
Become disabled within the initial 9F month period
!eave the original job for disability reasons
+r become eligible for 1ocial 1ecurity %isability 'nsurance within the initial 9F month period
and may terminate if
the employer stops plan coverage for all employees, or
you fail to pay the premium on time, or
you obtain coverage through another employer group plan, or
you elect to stop (+B$A and replace it with an individual health coverage, or
you become eligible for &edicare
M2DICA62 )#A$*8
.hat Is Medicare/
Medicare is a Health Insurance Program for(
.eople =I years of age and older.
1ome people with disabilities under age =I.
.eople with 5nd#1tage $enal %isease )permanent kidney failure reBuiring dialysis or a transplant*.
Medicare has %wo Parts(
.art A )Hospital 'nsurance* # &ost people donGt have to pay for .art A.
.art B )&edical 'nsurance* # &ost people pay monthly for .art B.
Above two are the most common plans, but one new plan has been introduced in 6an ;@@= is &edicare .art
%, which is a %$4/ 'nsurance plan. +nly the people having either &edicare .art A or B are eligible to take
.lan %.
Cou can choose different ways to get the services covered by &edicare. %epending on where you live, you
may have different choices. 'n most cases, when you first get &edicare, you are in the +riginal &edicare
.lan. Cou may want to consider a &edicare .rescription %rug .lan to add drug coverage. +r, you may want
to consider a &edicare Advantage .lan )like an H&+ or ..+* that provides all your .art A, .art B, and often
.art % coverage. Cou make a choice when you are first eligible for &edicare. 5ach year you can review your
health and prescription needs and switch to a different plan in the fall.
As long as you have both .art A and .art B, items covered by .art A and .art B are covered whether you
have the +riginal &edicare .lan, or you belong to a &edicare Advantage .lan )like an H&+ or ..+*.
Part - !Hospital Insurance"(
Helps .ay 0or
(are in hospitals as an inpatient, critical access hospitals )small facilities that give limited outpatient and
inpatient services to people in rural areas*, skilled nursing facilities )not custodial or long#term care*,
hospice care, and some home health care.

&ost people get .art A automatically when they turn age =I. They do not have to pay a monthly payment
called a premium for .art A because they or a spouse paid &edicare taxes while they were working.
'f you don8t automatically get premium#free .art A, you may be able to buy it if
Cou )or your spouse* aren8t entitled to 1ocial 1ecurity because you didn8t work or didn8t pay enough
&edicare taxes while you worked and you are age =I or older, or
Cou are disabled but no longer get premium#free .art A because you returned to work.
'f you have limited income and resources, your state may help you pay for .art A andJor .art B.
Part !Medical Insurance"(
Helps .ay 0or
%octorsG services, outpatient care, and other medical services that .art A doesnGt. .art B helps pay for these
covered medical services and items when they are medically necessary. .art B also covers some preventive
services.
Medicare is changing
%he Medicare system is 0uickly changing and the information here is intended for people who are already 12 years of age.
3ounger people should note that Medicare will probably change drastically before they are eligible for the coverage.
Medicaid for seniors!
Medicaid is a federally&funded program that funds health care for low income individuals and families. %he Medicaid
program began in 4512 and is funded by both federal and state governments.
Medicaid may be a good option for seniors who live on a fixed income and cannot afford to obtain the health care they need.
-dditionally, the Medicaid program can provide nursing home, adult daycare, and other long term care coverage to people
who meet certain eligibility criteria.
Medicaid beneficiaries do not need Medigap coverage since Medicaid will pay for their health care expenses. Individuals
within 4678 of the poverty line are eligible for coverage that will pay their Part premiums.
Medicare Supple"ent Insurance
$ince Medicare does not cover all health care expenses, Medicare supplement insurance is sold as supplemental health
insurance for Medicare recipients. %here are a number of gaps in Medicare coverage, so this Medicare supplement
insurance is often known as Medigap.
Medicare supplement insurance is not a federal program like Medicare. -lthough health insurance companies provide
Medicare supplement insurance coverage, they are strictly regulated by both the federal and state government.
Medicaid beneficiaries do not need Medicare supplement insurance coverage because Medicaid will pay for their health
care expenses. Individuals within 4678 of the poverty line are eligible for coverage that will pay their Part premiums.
$ee the section on Medicare for more information on Medicare Part - and .
%he ma9ority of Medicare recipients purchase Medicare supplement insurance. %he :$ has standardi'ed all Medicare
supplement insurance plans. %here are 47 types of Medicare supplement policies available.
,e0uired benefits under any Medicare supplement insurance plan(
12 hospital days beyond Medicare coverage !lifetime allowance"
Part - Hospital #oinsurance !provides for days 14&57"
Part - Hospital ;ifetime ,eserve #oinsurance !provides for days 54&427"
Parts - and three pint blood deductible
Part 678 #oinsurance
Additional #e$uire"ents
In the first 1 months that someone is eligible for Medicare, they must be accepted to any Medicare supplement insurance
policy being offered at that time.
Medicare supplement insurance companies may offer different plans to people with disabilities.
3ou are permitted to change your mind, cancel the plan, and receive a full refund up to <7 days after you purchase
Medicare supplement insurance.
What is MedicareAdvantage?
Medicare-dvantage is a private managed care health insurance plan for seniors with the standard Medicare benefits and
some supplemental benefits. $enior prescription coverage may be included with these benefits.
What is MedicareSelect?
Medicare$elect is a Medicare supplement plan or Medigap policy that is similar to a PP).
Medicare Drug /enefit (verview
.hat5 &edicare will provide voluntary prescription drug coverage of front#end and catastrophic prescription drug costs
with an area of no coverage in the middle )sometimes referred to as the Kdonut holeK*. 'n order to be covered under the
program, drugs must be approved for safety and effectiveness by the 4.1. 0ood and %rug Administration and must be
dispensed by prescription.
.hen5 (overage will be available beginning 6anuary 9, ;@@=. The initial enrollment period will begin -ovember 9I,
;@@I and extend to &ay >9, ;@@=. 0or years beginning with ;@@A, enrollment periods will be from -ovember 9Ith
through %ecember >9st of the prior year.
.ho is eligible5 All &edicare beneficiaries are eligible for voluntary drug coverage.
How will individuals get coverageL 'ndividuals will be able to obtain $x drug coverage from multiple sources new stand#alone
prescription drug plansM private plans )H&+s, ..+s, or private fee#for service plans also providing coverage of traditional
&edicare benefits*Mor employer#sponsored retiree health plans. &edicare cost contracts or .A(5 programs also will be allowed to offer
$x drug coverage to current enrollees.
.hen Does Medicare Drug Coverage /egin and How Can Individuals et Coverage5
.hen5 (overage will be available beginning 6anuary 9, ;@@=.
How5 'ndividuals will be able to obtain $x drug coverage from multiple sources including new stand#alone prescription
drug plans and private plans.
.hat does this mean for individuals5 Beneficiaries will be able to enroll in new &edicare drug coverage in 6anuary ;@@=,
and have a choice of at least two plans, at least one of which must be a stand#alone drug plan.
!e" 2lements
.hen does Medicare drug coverage begin5 &edicareGs new prescription drug coverage will become available
on 6anuary 9, ;@@=. An initial open enrollment period will begin -ovember 9I, ;@@I and extend through &ay
9I, ;@@=. 0or years beginning with ;@@A, open enrollment periods will be from -ovember 9Ith through
%ecember >9st of the prior year. 1pecial enrollment periods will be provided in certain situations, such as
involuntary loss of coverage or errors in enrollment.
How can individuals obtain drug coverage5 5ligible individuals can obtain &edicare prescription drug
coverage from the following sources
1tand#alone prescription drug plans # 'ndividuals in traditional &edicare or enrolled in private plans that are not
reBuired to provide prescription drug coverage )such as &edical 1avings Account plans or private fee#for#service
plans* can purchase coverage from new stand#alone drug plans.
.rivate &edicare plans that offer drug coverage # 'ndividuals enrolled in &edicare H&+s and ..+s ## or in
&edical 1avings Account plans or private fee#for#service plans that offer drug coverage ## must obtain their drug
coverage from their plan. )&edicare H&+s and ..+ are reBuired to provide &edicare drug coverage along with
traditional &edicare benefits.*
5mployer#sponsored plans # 'ndividuals eligible for employer#provided retiree health coverage can receive their
prescription drug coverage through such plans.
+ther sources # 'ndividuals currently enrolled in &edicare cost contracts or .A(5 programs that elect to provide
prescription drug coverage can obtain their drug coverage through such plans. &edicare cost contracts are
managed care plans that are reimbursed on a cost basis by the &edicare program. .A(5 ).rogram of All#
'nclusive (are for the 5lderly* programs are programs of comprehensive care that allows frail elderly people to
live in their communities.
0ederal fallback plan # The new law guarantees that individuals will have a choice of at least two prescription drug plans
)at least one of which must be a stand#alone drug plan*. 'f less than two drug plan options are available in an area, the
government will provide drug coverage through a federal fallback plan.
Dental Insurance 9 Dental Discount )lans
How Dental Insurance .orks
1ometimes you are reimbursed after you submit a claim with the health insurance company and other dental insurance
policies pay the provider directly. There is often a maximum benefit amount per year.
&any orthodontic and other special needs trigger a coinsurance reBuirement in dental insurance plans. &any routine
appointments, cleanings, and x#rays do not reBuire coinsurance contributions.
5mployers support nearly all dental insurance plans. Individual dental plans are hard to find, so many individuals will
purchase a dental discount plan in lieu of dental insurance.
%ental coverage for children may be included in the (hildren8s Health 'nsurance .rogram )(H'.*.
Differences /etween Dental Insurance and Dental Discount )lans
Dental Discount )lans
Dental discount plans are membership based programs with enrollment fees and monthly charges.
Dental discount plans are unregulated.
Dental discount plans can charge any amount to provide any services and switch them at any time.
1alespeople do not need to obtain a license or have any experience in the dental care or dental insurance fields
to offer dental discount plans.
7ith a dental discount plan, you still pay the bills. Cou just get a lower price where the discount card is
accepted.
-etwork si,e for dental discount plans can be extremely limited. Be certain that there are providers in your area
and be aware that the providers may revoke their membership in the dental discount plan at any time.
1ome dental discount plans offer discounts on cosmetic procedures not covered by dental insurance.
Dental Insurance
Dental insurance has premiums, co#payments, and deductibles.
After the deductible is met, all costs are covered, up to the annual maximum benefit.
Dental insurance policies are only sold by licensed professionals.
Dental insurance is regulated by state governments.
Typical services covered by dental insurance
%ental checkups and cleanings every = months
"#rays )as needed*
+ral surgery, tooth extraction, and root canals
0illings, dentures, crowns, bridges, dentures )prosthodontics*
Treatment of gum diseases and other periodontal tissues
+rthodontics )braces, retainers, etc.*
-ision Insurance Coverage
.hat Does -ision Insurance Cover5
Vision insurance covers care and treatment for your eyes. These plans often cover annual eye exams, glasses, contacts,
and glaucoma screening. !aser eye surgery is even covered with some vision plans. Vision Insurance can be extremely
restricted. 1ome policies just pay for the annual exam or treatment of eye conditions, not glasses or contacts.
How Does -ision Insurance .ork5
Cou may have to pay the doctor yourself and submit a claim for the vision insurance company to reimburse you later.
+ther plans pay the eye care provider directly.
Vision insurance is not a substitute for health insurance. 'n fact, most often a medical problem discovered by your eye
doctor )such as a cyst or tumor in your eye* would fall under your health insurance, not your vision insurance.
Do I $eed -ision Insurance5
Cou might find that vision insurance could help you get a discount on the glasses or contacts that you need anyway.
&any vision insurance plans are supported by employers, but if youGre looking for a vision plan on your own, shop
around and compare the cost and benefits offered with each plan.
Health Insurance ost onsiderations
%educti&les' o(Pay"ents' and oinsurance
3ou will nearly certainly pay a deductible before the health insurance plan will chip in for your health care. %his is usually an
annual amount, which can range from =477 to several thousand dollars.
#o&payments are charged for medical services individually. +or example, a doctor visit might have a =<7 co&payment per
visit or a prescription may have a =47 co&payment for each medication.
#oinsurance is not part of every health insurance policy, but it is the percentage you must pay after the deductible is met. If
coinsurance is part of your policy, you might be responsible for 678 or more of the cost of medical care !after the
deductible".
$ational )rovider Identifier
$)I Information 6esources
B(B1A has developed -ational .rovider 'dentifier )-.'* resource tool for healthcare providers, both for large practices
and institutional providers and for individual providers and small group practices, that give an overview of the H'.AA#
mandated -.' reBuirements. The tool explains why it is important for providers to act now in regard to obtaining,
reporting and implementing their -.'s and suggests actions that providers can take to ensure compliance by the &ay
;@@A deadline. The resource guides are intended for educational purposes only.
The -ational .rovider 'dentifier )-.'* is a H'.AA#mandated national standard adopted by the 1ecretary of Health and
Human 1ervices for use in the health care industry. By no later than &ay ;>, ;@@A, all covered providers,
clearinghouses, and health plans )except for very small health plans that have an additional year* must have completed
their -.' transition process. The -.' is not just a simple new number. Because it is essential to authori,ations, billing,
payment, care coordination, reporting, etc., -.' implementation is complex.
+btaining your -.' is but the first step in the implementation process. This resource tool N intended for use by
hospitals, physicians, and other professional providers of non#institutional health care services in large group practices N
explains the actions that you will need to take after you get your -.' to assure successful implementation. Because of
the time needed to complete these actions, it is important that you do not delay in getting your -.'. 'f you do not allow
sufficient time to complete these actions, then you will not be in compliance with the federally mandated set of
reBuirements, and you could experience payment delays, denials, and incorrect allocations. This resource tool was
prepared under contract to the Blue (ross and Blue 1hield Association by 7alter /. 1uare,, &%, .resident and (5+,
'nstitute for H'.AAJH'T
5ducation and $esearch, and (o#chair of the 7orkgroup for 5lectronic %ata 'nterchange )75%'* -.' +utreach 'nitiative.
This tool is intended for educational purposes only. 1hould you or your company have specific Buestions on how to
comply with the -.' reBuirements set forth here, we recommend that you consult with your legal counsel.
The -.' is a new 9@#digit '% issued by the federal government to individual providers, as well as small and large
provider organi,ations. The 9@#digit '% is Dintelligence#freeE in that it does not have any coded information embedded
into it, nor does it communicate specific characteristics of the health care provider it identifies. 'ndividual providers such
as physicians, dentists, nurses, chiropractors, and therapists
will be able to obtain only one -.' for themselves. .rovider organi,ations such as hospitals, medical or dental group
practices, nursing homes, pharmacies, and laboratories, will be able to obtain one -.' for the organi,ation and one -.'
for specific components of the organi,ation )known as D1ubpartsE*. +nce assigned, the -.' of a provider will not change.
't will remain the same regardless of change in location, scope of practice, or any other factor, except in certain
circumstances such as when an individual provider retires, an organi,ation provider ceases to exist, or a provider8s -.'
is being used fraudulently. The -.' is reBuired to be used as the only identifier for health care providers that are
listed and reported in H'.AA standard transactions. H'.AA standard transactions include health care claims, claim
payments, eligibility, and referrals. Health care providers generally listed in these transactions include the billingJpay#to
provider, rendering provider, referring provider, attending physician, and operating physician.
.hat is the $ational )rovider Identifier
A H'.AANmandated national standard
O A new 9@#digit, Dintelligence#freeE '% for health care providers
O 'ssued by the 0ederal government to individual providers as well as small and large provider organi,ations
O +ne -.' per individual providerM one or more -.'s to uniBuely identify an organi,ational provider and its subparts
O .ermanently assigned, and not expected to change
O $eBuired to be used in H'.AA standard transactions )e.g., claims, claim payment, eligibility, referrals*
The -.' will allow the health care industry to rely upon a single uniBue identifier for each provider, rather the various
health plan#specific identifiers currently in use. The -.' will replace all other provider identifiers used in H'.AA standard
transactions, including &edicare8s 4.'-s, &edicaid .rovider 'dentifiers, and health plan#specific provider '%s. The -.'
will simplify the billing process for providers by using a single national provider identifier standard across all health plans
and clearinghouses when submitting and receiving H'.AA standard transactions.
The -.' will facilitate the process of coordinating benefits )(+B* across health plans, by having (+B transactions
contain the same provider identifier regardless of which health plan is doing the (+B.
.h" is the $)I $eeded
O 5liminate all health plan#specific provider identifiers used in the health care industry N All health plan#specific
identifiers )such as
&edicare8s 4.'-, &edicaid provider '%s, private health plan provider '%s* will be replaced by -.' O 1implify provider
billing
O 0acilitate conducting coordination of benefits
The -ational .rovider 'dentifier
All entities covered by the H'.AA !aw are reBuired to comply with the -.' regulations. (overed entities must be able to
accept -.'s and process information using -.'s.
(overed entities include all health plans )including &edicare, &edicaid, and private insurance plans*M all clearinghouses
)companies that receive, process, or facilitate the processing of health care transactions between providers and health
plans from a nonstandard format into a H'.AA standard format, or vice versa*M and health care providers that transmit
health care transactions in electronic form.
All health care providers, regardless of whether they are covered or not by H'.AA, are 5!'/'B!5 to obtain an -.'. +nly
those health care providers that are covered by H'.AA are $5P4'$5% to obtain and use their -.'s. A health care
provider is defined in H'.AA regulations as a provider of services )a hospital, critical access hospital, skilled nursing
facility, comprehensive outpatient rehabilitation facility, home health
agency, hospice program*, a provider of medical or health services )physician services, certified nurse#midwife services,
Bualified psychologist services, clinical social worker services*, and any other person or organi,ation who furnishes, bills,
or is paid for health care in the normal course of business.
.ho is *ubject to Compl" with the $)I
O All Dcovered entitiesE are reBuired to comply with the -.' regulations N (overed entities include health plans,
clearinghouses, and health care providers that transmit administrative transactions electronically
O All health care providers are eligible to obtain an -.' O (overed health care providers are reBuired to obtain and use
their -.'s
The -ational .rovider 'dentifier
&ost individual health care providers that are identified in transactions )for example a physician being reported as the
rendering provider in a professional claim or the attending physician in a hospital claim* will need to have their own
individual -.', which will need to be reported in the appropriate location in the claim transaction.
An organi,ational health care provider that conducts transactions electronically and is the legal entity billing for health
care services must obtain an -.' for its own use.
The legal organi,ation may also choose to obtain separate -.'s to identify components )known as 1ubparts* of the
organi,ation. 0or example, a hospital may choose to identify one of its units, the $ehabilitation 4nit, with an -.' that is
different from the hospital -.'. There are certain conditions that subparts must meet
O 1ubparts cannot be a separate legal entity from the DparentE organi,ation.
O A 1ubpart must provide health care services to be eligible for an -.'.
O A 1ubpart may or may not be located at the same location as the parent organi,ation or have the same taxonomy
code as the parent organi,ation.
O D1ubpartingE is an option, not a reBuirement )except when the subpart conducts its own transactions, separate from
the parent organi,ation, +$ when the subpart would be a covered health care provider if it were a separate legal entityM
in these two cases the subpart &41T obtain an -.'*.

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