INDIVIDUAL HEALTH INSURANCE MANDATE AND

INDIVIDUAL HEALTH INSURANCE MANDATE AND

CHAPTER 1

THE AFFORDABLE CARE ACT (ACA)
AND HOW IT FITS WITH OTHER MEDICAL PROGRAMS

How Does The ACA Affect My Family And Me, and What Other Medical Programs May Affect Us?

Questions answered in this chapter--

1. Should I read this whole book?

2. How does the ACA fit into the big picture of health coverage?

3. How can this book help me?

4. Does the ACA affect me?

5. When is the ACA effective?

6. How should I use this book?

Internet Sites

7. Where can I find help on the internet?

CHAPTER 2

NO-COST PREVENTIVE CARE SERVICES

Two Of The Most Controversial Parts Of The ACA Are Discussed

Questions answered in this chapter—

Required Coverage

1. If I am not covered by health insurance that provides “minimum essential coverage,” will I have to pay under the “individual mandate”?

2. If a penalty applies for not having minimum essential coverage, how is the penalty determined and who pays the penalty?

3. How is my “household income” determined?

4. What if I have health coverage for part of the year but not all?

5. Will I meet the individual coverage or mandate requirements of the ACA if I have “minimum essential coverage?”

6. What are the exceptions to the individual mandate?

No-Cost Preventive Care

7. What preventive and wellness care services are required to be provided at no cost under the ACA?

8. The requirement of no cost preventive care regarding reproduction is very controversial; what is the background?

Internet Sites

9. Where can I find help on the internet?

CHAPTER 3

EMPLOYER-PROVIDED HEALTH COVERAGE

Your Right For Information; Important Decisions You Must Make;

And Whether You Are Entitled To Subsidized Premium Support From The Insurance Exchange

Questions answered in this chapter—

What Coverage Does My Employer Provide?

1. Does my employer provide health insurance?

2. When should I get a Summary of Benefits and Coverage (SBC) from my employer and what will it tell me?

3. What does health coverage provided by an employer cost?

4. Are health benefits provided a Point-of-Service (POS) Arrangement, Health Maintenance Organization (HMO), or a Preferred Provider Organization (PPO)?

5. What is an HMO?

6. Who usually likes an HMO?

7. What is a PPO?

8. Who usually likes a PPO?

9. What are copays, deductibles, coinsurance, and out-of-pocket limits?

Does My Employer’s Plan Meet ACA Requirements?

10. Is my employer’s plan “grandfathered”?

11. Does my employer’s health plan provide the coverage under the ACA it is required to provide? and does the health plan offer the coverage under the ACA I am required to have?

12. Does my employer’s plan provide “essential health benefits”?

13. Does my employer’s plan provide “minimum value”?

14. Must my whole family be offered coverage under my employer’s health plan?

Is My Employer’s Plan “Affordable”?

15. Is my employer’s plan “affordable” and why is that important to me?

16. Is there an easy way to determine if the cost of my coverage is 9.5% or less of my “household income” and so is “affordable”?

17. How is my “household income” determined?

18. If my employer’s health plan is “affordable” under the ACA, what does that mean for me and my family? What if it is not “affordable?”

19. What if my “household income” or family size changes during the year?

20. For what period of time is a determination made as to whether employer-provided health coverage is “affordable?”

21. Is my “household income” 400% or less of the federal poverty level (FPL)?

Will I be Entitled to Premium Payment Assistance and Other Help on the Insurance Exchange?

22. If the cost of my health plan is more than 9.5% of my household income, and my household income is 400% or less of the FPL what should I do?

23. Is there other assistance for lower income individuals who purchase policies on the Insurance Exchange?

Internet Sites

25. Where can I find help on the internet?

CHAPTER 4

USING THE INSURANCE EXCHANGE TO BUY AN INDIVIDUAL HEALTH INSURANCE POLICY

When You Can Use The Exchange; How To Use It;
And What Premium Assistance You May Be Entitled To When
Buying a Policy on the Insurance Exchange

Questions Answered in this chapter—

1. Do I need to buy an individual health insurance policy?

2. How can I shop for an individual insurance policy?

3. What is the Insurance Exchange and what insurance plans are offered on it?

4. What is a qualified health plan (QHP)?

5. Is there anyone who can help me with this who is neutral and will look out for me?

6. What factors enter into the different premium costs of bronze, silver, gold and platinum level plans?

7. Am I eligible to purchase an individual policy through the Insurance Exchange?

8. Can health policies for children be purchased through the Insurance Exchange?

9. How will the Insurance Exchange help me find and pay for the right policy?

10. What if I have a pre-existing condition?

11. If my employer is a “small employer” (less than 100 full-time or full-time equivalent employees) will it be able to buy policies for all its employees through the Insurance Exchange.

Financial Assistance in Buying a Policy on the Insurance Exchange

12. How is my “household income” determined?

13. How is the federal poverty level (FPL) determined?

14. If my household income is 400% or less of the FPL, will I get premium assistance credit from the Insurance Exchange?

15. What if my “household income” or my family size changes during the year?

16. For what period of time is a determination made as to whether employer-provided health coverage is “affordable?”

17. What if I marry or divorce during the year?

18. What happens when a single family policy is shared by two families, such as when an adult child under age 26, but not living at home, is covered by the policy?

19. How is the amount of premium assistance credit tied to the “second lowest cost silver level policy”?

20. Is additional assistance available through the Exchange if my household income is below 400% of the federal poverty level (FPL)?

21. What if the financial assistance I receive through the Exchange turns out to be more or less than I am entitled to for the year?

22. What is a “basic health plan,” and will it be offered in my state?

23. Is financial help available outside of the Exchange?

Internet Sites

24. Where can I find help on the internet?

CHAPTER 5

WILL THE ACA INCREASE MY TAXES?

The Effect On Income And Payroll Taxes For The Well Off, And Taxes For Small Businesses

Questions answered in this chapter--

Personal Tax Liability

1. Will the ACA reduce or increase my taxes?

2. Will I have to pay a tax penalty if I am not covered by health insurance?

3. If a family dependent or I participate on the Insurance Exchange and receive too much premium assistance credit, will I be liable?

Business Tax Liability

4. If I am a small employer, will my business be subject to increased taxes?

5. If my company is a large employer (50 or more full-time employees), will there be penalties if the employees are not provided with health coverage?

6. Are there other special taxes under the ACA that are imposed on businesses in the health care industry?

Internet Sites

7. Where can I find help on the internet?

CHAPTER 6

HOW THE ACA AFFECTS EMPLOYERS

When Employers Will Be Treated As Having 50 Full-Time Employees And Be Subject To the

“Shared Responsibility” Requirement; Temporary Tax Credits For Small Employers That Provide Health Coverage

Questions answered in this chapter--

Less than 50 Full-Time Employees

1. I am a small business owner; how will the ACA affect my business?

2. If my business is not a “large employer,” will there still be requirements it must meet under the ACA?

3. If my business has approximately 50 full-time employees, how can I be sure whether it is a “large employer” or a “small employer”?

50 or More Full-Time Employees

4. Can you give me a brief summary of how to determine whether my business has 50 or more full-time employees; and if it does, what responsibility it has under the ACA to provide health coverage to its employees?

5. Is there any exception to the rule that a large employer must provide health plan coverage beginning January 1, 2015?

6. When is the 50 or more full-time employees threshold determined?

7. Who qualifies as a full-time employee?

8. How are part-time employees counted as full-time equivalent employees?

9. Is a variable-hour employee treated as a full-time or a part-time employee?

10. Do part-time employees count in determining whether the employer has 50 or more full-time employees?

11. Do seasonal employees count in determining whether the business has 50 employees?

12. Do leased employees count in determining whether the business has 50 employees?

13. Must employees residing outside the United States be counted?

14. How soon after they are hired must full-time employees be offered health coverage?

15. What coverage is a “large employer” required to provide?

16. What is the penalty for failing to provide health coverage that meets the requirements of the ACA?

17. What if a large employer overlooks a few full-time employees in providing coverage (95% or 5 employee safe harbor)?

18. If my business has a medical plan established under a collective bargaining agreement, how will that be affected by the ACA?

19. How will the IRS determine and assess a penalty if a large employer does not provide “affordable” “minimum essential coverage?”

20. Must the employer report medical coverage information on W-2s?

21. If I own several businesses, either alone or with others, will they be grouped together to determine if there are a total of 50 full-time employees?

22. If my business is a large employer should it offer employees health coverage that meets the requirements of the ACA?

23. Can my business provide health plan coverage on a basis that discriminates in favor of management employees?

24. Is there automatic health plan enrollment for employers with more than 200 full-time employees?

25. How do small employers (100 or fewer full-time employees) purchase a health plan for their employees on the Small Business Health Options (SHOP) exchange?

Cadillac Plan Tax

26. What is the “Cadillac Plan” tax, and who pays it?

Other ACA Penalties Imposed On Employers

27. Are there penalties for retaliating against an employee in ACA related matters?

28. Is there any other penalty of concern to an employer that does not comply with the ACA?

Tax Credit If Less Than 25 Full-Time Employees

29. What if my business has less than 25 full-time employees, and I do provide health insurance to my employees?

30. How much is the credit?

31. What is an example of how the credit is computed for any of the years 2010 through 2013?

32. Can you give me an example of how the credit is computed for any two consecutive years beginning in 2014?

33. As a business owner, is the amount paid for my health insurance and that of my family eligible for the tax credit?

Internet Sites

34. Where can I find help on the internet?

CHAPTER 7

MEDICARE

Coverage, Cost, Choices Available, Including Medicare Advantage, Medigap, And Part D Prescription Drug Coverage

Questions answered in this chapter--

1. An overview of Medicare.

Coverage and Payments for Parts A & B of Medicare

2. What are the eligibility requirements for Medicare?

3. If I must pay for Part A coverage, what will it cost, and is there a penalty for delayed coverage?

4. If I am eligible for Medicare, when and how should I apply if I just want Medicare Part A coverage?

5. What if I want to enroll in Medicare Parts A and B or want coverage under a Medicare Advantage plan?

6. If I can’t afford the cost of Part B coverage, can I get any help in making payments?

7. I am eligible for Medicare but I am still employed and covered by my employer’s health insurance; what should I do?

Explanation of Parts A, B, C, and D Coverage

8. Briefly, what are Parts A, B, C and D coverage?

9. Are there other plans that provide Medicare coverage?

Part A Coverage (Hospitals and Skilled Nursing Facilities)

10. What does Part A coverage provide?

11. How long a stay does inpatient hospital care cover and what benefits does it provide?

12. What is inpatient care in a skilled nursing facility (SNF) and what benefits does it provide?

13. What requirements must be met to qualify for care in an SNF?

14. Is nursing home care covered under Part A? What about home health care?

15. I understand hospice care is available under Part A; what does it include?

16. What is inpatient care in a religious nonmedical health care institution?

Part B Coverage (Doctors, Medical Procedures and Other Expenses)

17. What does Part B coverage provide?

18. What does Part B coverage cost?

19. If I sign up for Part B coverage as soon as I am eligible, can I be sure that I will only pay the minimum per month?

20. How does Medicare figure my “modified adjusted gross income” (MAGI)?

21. If my MAGI puts me in a higher premium category than the basic premium, is there anything I can do to lower my premiums for this year?

22. Even if I can’t reduce my premiums for this year, is there anything I can do for future years?

23. Should I sign up for Part B coverage if I am still employed and covered under my employer’s health care plan?

Part C Medicare Advantage and Other Special Medicare Programs

24. Is one of the Medicare Advantage programs right for me?

25. Will Medicare Advantage change under the ACA?

26. Are there online guides that can help me choose the right plan?

27. Is there a best time to enroll in a Medicare Advantage program?

28. What is a Medicare Special Needs Plan and is it the right choice for me?

29. How much does a Medicare SNP cost?

30. What is a Medicare Medical Saving Account?

Mental Health Treatment

31. Are there special coverage restrictions for mental health treatment?

Part D Insurance Coverage (Prescription Drugs)

32. What does Part D coverage cost?

33. How does Part D coverage work?

34. What exactly is the “doughnut hole”?

35. Should I sign up for Part D coverage?

36. When can I purchase Part D insurance?

37. Is there a penalty for not enrolling in Part D when I am first eligible?

38. Do I have a doughnut hole if I am covered by both Medicare and Medicaid?

39. Is there any program to help me pay the cost of Part D coverage?

40. Can I automatically qualify for Extra Help?

41. If I do not automatically qualify, what are the income and asset limitations of Extra Help?

42. How do I apply for Extra Help?

Medigap Insurance Coverage

43. What is Medigap coverage, and why might I need it?

44. How are premiums determined for Medigap policies?

45. Are there any other suggestions on how to determine which Medigap plan is best for me?

46. What are the enrollment periods for Medigap policies?

47. Can I switch Medigap policies; if so, what is the best way to do that?

48. Can I have Part D prescription drug coverage as part of my Medigap policy?

49. Will Medigap policies be available if I live in Massachusetts, Minnesota, or Wisconsin?

50. What Medigap policies are available in Massachusetts?

51. What Medigap policies are available in Minnesota?

52. What Medigap policies are available in Wisconsin?

53. Is a Medigap policy a good idea for me?

Medicare Complaints and Appealing Decisions

54. What if I have a complaint about the service provided to me or a member of my family under Medicare?

55. What if I want to file a Medicare claim?

56. If I do not agree with a Medicare decision, can I appeal it?

57. Can I appoint a representative to file an appeal for me?

58. What additional steps should I take before filing an appeal under my Prescription Drug plan?

59. What steps are involved in appeals Levels 1 through 5 with Original Medicare?

60. If I have a Medicare Advantage or Medigap plan or a Part D plan, what steps are involved in appeals Levels 1 through 5 as compared with Original Medicare?

Internet Sites

61. Where can I find help on the internet?

CHAPTER 8

MEDICAID

Coverage For Children, Pregnant Women, The Disabled, And Seniors;
Determining Eligibility And Benefits

Questions answered in this chapter--

General

1. What is Medicaid?

2. Are the benefits provided by Medicaid the same in each state? If not, why are they different?

3. How are Medicaid services provided?

4. Are there any premiums, copayments, or other costs associated with Medicaid?

5. How will the ACA affect Medicaid programs?

Medicaid Eligibility Requirements

6. What are the eligibility requirements for Medicaid?

7. What is the difference between “family income” for Medicaid and “household income” under the ACA?

8. What does “spend down” mean when a program is concerned about income eligibility level?

Medicaid Programs

9. What health programs are available for children under Medicaid?

10. What Medicaid assistance is available to pregnant women?

11. What coverage is provided for non-disabled, low-income parents and caretaker relatives?

12. Will the ACA provide greater coverage for adults?

SSI, Section 209(b) Qualified Individuals; Poverty Level and Medically Needy Coverage; and Special Income Rule Individuals

13. Are individuals who are receiving SSI assistance eligible for Medicaid?

14. What Medicaid assistance is provided to SSI or to section 209(b) qualified individuals?

15. What is SSI?

16. What are “SSI states”?

17. What are “section 209(b) states”?

18. What are “poverty level coverage,” “medically needy” and “special income rule” programs?

19. If I am disabled and receiving SSI or section 209(b) state assistance and I am returning to work, will I be entitled to any continuing Medicaid benefit?

Assistance for Seniors, MSP, and PACE

20. What Medicaid assistance is available for seniors, other than long-term care?

21. What are the requirements for participation in the MSP programs (also called the Medicare Premium Payment Programs)?

22. What is the PACE program?

Long-Term Care Services for Seniors

23. Does Medicare or Medicaid cover long-term care needs?

24. What community-based services are provided for seniors as an alternative to long-term care services?

25. How is long-term care assistance provided for seniors who need assistance in activities of daily living (ADL) such as dressing, bathing, toileting, and eating?

26. What programs of federal, state, or local government assistance are available to help seniors live in their own home or apartment?

27. If a senior is living in his or her home or apartment and receiving long-term care, what sensible steps can be taken to reduce the cost of that care without lessening the quality?

28. What kind of assistance for long-term care does Medicaid provide?

29. Does Medicaid typically pay all long-term care costs for eligible seniors?

30. What are the Medicaid eligibility requirements for long-term care for seniors?

Avoiding “Spousal Impoverishment” and Medicaid Planning for Seniors

31. With a married senior receiving Medicaid long-term care, how do the “spousal impoverishment” rules apply?

32. Can I give away assets, such as a house, to family members or sell them in “bargain sales” in order to avoid turning over the assets to Medicaid?

33. What other assets have special restrictions?

34. What happens if the house my spouse and I own has a value in excess of $500,000?

35. What happens to the house owned by a married couple following the death of both spouses?

Internet Sites

36. Where can I find help on the internet?

CHAPTER 9

ACTIVE DUTY SERVICE PERSONNEL AND VETERANS

TRICARE® Coverage For Active Duty, Families, Reservists, Retired Military, And
Veterans, Including Those With Military Disabilities

Questions answered in this chapter--

1. What are the different TRICARE and other programs for providing medical and dental benefits to active and retired military personnel and their families?

2. Who is a “sponsor” and who is a “dependent”?

3. What is TRICARE Prime?

4. Chart comparing the cost of TRICARE Prime, TRICARE Extra, and TRICARE Standard, as of 2011—2012.

5. What is the US Family Health Plan?

6. What is the TRICARE Point-of-Service Option?

7. What is TRICARE Standard?

8. What is TRICARE Extra; and what is the difference between TRICARE Standard and Extra?

9. What is TRICARE Prime Remote?

10. What is TRICARE Prime Overseas?

11. What is TRICARE Prime Remote Overseas?

12. What programs are available to National Guard/Reserve and Retired Reserve members and their families?

13. What is the Transition Assistance Management Program (TAMP)?

14. Am I eligible for TRICARE for Life (TFL)?

15. If I am the widow of a deceased service member, what coverage rules apply to me?

16. If I am the divorced spouse of a service member, am I eligible for coverage?

17. I am no longer eligible for coverage under my parents’ TRICARE plan, should I consider TRICARE Young Adult?

18. What is the TRICARE Active Duty Dental Program?

19. What are the main features of the TRICARE Dental Programs, other than the Active Duty Dental Program?

20. Am I eligible for the TRICARE Retiree Dental Program, and what are the major features of this program?

21. How does the TRICARE Pharmacy Program work?

22. If the service provider does not file a claim for me when and how should I file a claim?

23. What kinds of appeals are available to me or a dependent under TRICARE?

Veterans With Disabilities Or Needing Long-Term Care

24. Is there assistance for Veterans who are not eligible for TRICARE?

25. Is there assistance for low income Veterans who are seniors and need home care or long-term care assistance?

Internet Sites

26. Where can I find help on the internet?

CHAPTER 10

DOMESTIC PARTNERS

Same-Sex Or Opposite-Sex; Problems Of Entitlement To Coverage And To Tax Equality

Questions answered in this chapter--

1. Healthcare related tax differences between same-sex and opposite-sex domestic partners

Same-Sex Domestic Partners

2. What is the effect of the Supreme Court''s decision in Windsor v. Windsor, which declared part of the DOMA unconstitutional?

3. Why are tax benefits important in lowering my health care costs?

4. What favorable tax treatment do opposite-sex married couples get with respect to health care expenses?

5. Can married same-sex partners be treated as “spouses” for purposes of federal law?

6. Who is a “dependent” for purposes of medical expenses and deductions?

7. Are there ways under present federal tax law that same-sex partners not living in a state that recognized same-sex marriage can receive favorable tax treatment for medical coverage received through one partner’s employer, or can they deduct large medical expenses made on behalf of one of the partners?

8. What is the tax treatment of employer-provided health coverage of children of same-sex partners?

9. Are there other health coverage related issues under DOMA?

10. What health coverage is available to my domestic partner and me under my employer’s health plan?

11. Will family coverage be available to my partner and me through a policy purchased through the Insurance Exchange?

12. Does the ACA make any changes in the law with respect to health insurance for same-sex domestic partners?

Opposite-Sex Unmarried Domestic Partners

13. How does my having an opposite-sex domestic partner affect my getting health plan coverage if we have a common-law marriage?

14. If you do not have a common law marriage, what concerns about health plan coverage should you and your opposite-sex partner have?

Internet Sites

15. Where can I find help on the internet?

CHAPTER 11

RETIREE HEALTH COVERAGE

If Retiree Health Coverage Is Provided By A Private Or Governmental Employer,

What You Must Do To Be Entitled To It; Can It Be Taken Away?

Questions answered in this chapter--

1. What kinds of retiree health coverage are there?

2. How can I be sure that I am covered?

3. Can I be sure that my retiree coverage will continue?

Internet Sites

4. Where can I find help on the internet?

CHAPTER 12

COVERING CHILDREN UNDER AGE 26 AND YOUNG ADULTS TO AGE 30

Whether You Are A Parent Or An Adult Child, Know Your Coverage Rights And
When It Is Best To Switch Coverage; And Learn How You Can Obtain
Lower Cost “Catastrophic Coverage” Under The ACA

Questions answered in this chapter--

Coverage Under Parents’ Policy or Plan

1. Can I be covered under my parents’ health plan to age 26?

2. What is the cost of covering children to age 26?

3. Is there any tax cost for a plan covering my adult children?

4. What happens to my adult child’s coverage when he or she becomes age 26?

Financial Help for Coverage

5. Are my children eligible for Medicaid or CHIP?

6. What kind of coverage is provided for children?

Coverage for Young Adults

7. Do I have to get health insurance coverage and is special “catastrophic” coverage available for my age group?

8. Does the insured have to be under the age of 30 at the beginning of the plan year to qualify to buy “catastrophic” coverage?

9. If I have a parent in the military am I eligible for TRICARE Young Adult?

10. Would it be a “good gamble” for me not to get any insurance coverage at this time in my life?

Internet Sites

11. Where can I find help on the internet?

CHAPTER 13

COBRA

Health Continuation Coverage When You Lose Coverage Under An Existing Policy

And Whether Cobra Coverage Is Important When Pre-Existing Conditions Are Covered By The ACA

Questions answered in this chapter--

1. What is COBRA coverage?

2. Why is COBRA coverage still important after 2013 when there are no pre-existing conditions?

3. Are there alternatives to COBRA coverage?

4. Can having COBRA coverage prevent me or my dependents from qualifying for financial assistance on the Insurance Exchange?

5. What are the events that permit special enrollment in the health plan offered by my spouse’s employer?

6. How long does COBRA coverage last?

7. Are there special rules that apply to disability?

8. Should I or a family member elect COBRA coverage?

9. What does COBRA coverage cost and when do I have to pay for it?

10. If I cannot afford the cost of COBRA coverage, can I get financial help in paying the premiums?

11. Can I change the kind of COBRA coverage I have?

12. Is my employer required to offer COBRA coverage?

13. Who in my family is required to be offered COBRA coverage?

14. Exactly how is COBRA coverage offered by the employer?

15. How will my employer know that it should send me or a family member a COBRA coverage notice?

16. If I am fired, can the employer refuse to offer me or my family COBRA coverage?

17. Once I and my family get a COBRA coverage package, what do we need to do to elect COBRA coverage?

18. Should I send my election of COBRA coverage to my employer?

19. When must I pay my COBRA premiums?

20. If my family or I have COBRA coverage, can we change our coverage elections?

21. Can I get information from my employer about COBRA coverage?

22. If my employer failed to provide me with a COBRA coverage notice, have I lost my chance to elect to be covered?

23. If I did not timely receive a COBRA notice, did not get replacement insurance, and now have a medical condition requiring expensive medical treatment, what can I do?

24. What is a “Certificate of Creditable Coverage”?

Internet Sites

25. Where can I find help on the internet?


CHAPTER 14

PRE-EXISTING CONDITIONS AND WELLNESS PROGRAMS

Getting And Keeping Insurance If You Have Pre-Existing Conditions - Both Before And After The ACA; And Wellness Programs Under The ACA

Questions answered in this chapter--

Pre-Existing Conditions

1. What are pre-existing conditions?

2. What problems arose prior to the ACA with respect to pre-existing conditions?

3. Are all of these problems solved under the ACA?

4. Will the ACA completely eliminate pre-existing condition concerns by 2014?

5. Is there any insurance available before 2014 for people who have a pre-existing condition but do not have insurance?

6. What is “creditable coverage”? Why is it important before January 1, 2014, and will it still be important on and after January 1, 2014?

7. Will there be any pre-existing condition issues on and after January 1, 2014?

Wellness Programs

8. What are wellness programs?

9. What is the relationship between pre-existing conditions and wellness programs?

10. What restrictions are placed on an employer offering a wellness program that rewards participation with lower premium cost to the employee?

11. If my group health plan offers a wellness program, is it a burden or an opportunity?

Internet Sites

12. Where can I find help on the internet?

CHAPTER 15

CLAIMING BENEFITS AND APPEALING DENIALS OF COVERAGE BY

EMPLOYERS, INSURANCE COMPANIES, OR THE GOVERNMENT

What Health Plan Or Health Insurance Decisions Can You Appeal
And How Should You Go About It?

Questions answered in this chapter--

1. What kind of health plans are discussed in this chapter?

Filing a Claim

2. I believe I have a proper claim under my employer-provided health plan or individual health insurance policy; can I file a claim?

3. My employer’s health plan is self-insured; is there any difference in how I should file a claim?

4. How should I file a claim?

5. How long should it take to approve or disapprove my claim?

Appealing a Claim Denial

6. What information should I receive if my claim is denied?

7. If I am covered by an employer-provided plan or an individual health insurance policy, what can I do if my claim for treatment, benefit coverage, or claim reimbursement is denied?

8. Should I appeal a decision made by my health plan or health insurer?

9. Is there any chance that my claim was denied because denying it would save the insurer or plan money?

10. If I have decided to appeal the decision, how do I go about it?

11. How long does the review committee have to consider my appeal and how will I know what it has decided?

12. What should I do if my appeal is denied?

13. Do I have an external appeal right?

14. Should I go to court if my claim was denied?

15. How can I find a lawyer who is qualified to represent me?

Internet Sites

16. Where can I find help on the internet?

CHAPTER 16

GOOD WAYS OF SHOPPING FOR LOW COST PRESCRIPTION DRUGS

Wise Shoppers Can Save 50% Or More On Prescription Drug Costs

Questions answered in this chapter--

1. Am I already covered by insurance that provides for prescription drug coverage?

2. What is a generic form of a prescription drug, and will using it save me money?

Discount and Assistance Programs

3. Do some pharmacies offer special discount programs that make purchasing generic drugs less expensive?

4 What should I expect of a mail order pharmacy?

5. What if I don’t have health insurance to cover prescription drug expenses?

6. Is there other financial help available?

Purchasing Prescription Drugs Outside the United States

7. Will I save money if I purchase prescription drugs from sources located in foreign countries?

8. Is it legal for U.S. residents to purchase prescription drugs from other countries?

9. Are prescription drugs purchased from foreign countries safe?

10. Can I purchase prescription drugs overseas if I am in the United States?

Internet Sites

11. Where can I find help on the internet?


CHAPTER 17

HEALTH SAVINGS ACCOUNT (HSA), MEDICAL SAVINGS ACCOUNT (MSA),

AND FLEXIBLE SPENDING ACCOUNT (FSA)

How These Programs Can Save You Tax Dollars

Questions answered—

1. Are there programs that permit me to pay for medical expenses in pre-tax dollars?

Health Savings Account (HSA)

2. What is a health savings account (HSA) and will it help me?

3. What is the most I can contribute and deduct to an HSA each year?

4. What can I use the money in my HSA for?

5. What if I distribute money out of the HSA and don’t use it to pay medical expenses?

6. What dollar limitations apply to an HSA and to a high-deductible health plan (HDHP) ?

7. Can my employer offer an HSA?

8. What can I do to help keep my family’s and my health care costs under control?

9. Should I buy additional insurance to cover the gap between what the HDHP and the HSA covers and what my actual medical costs might be?

10. What if I have an Archer Medical Savings Account instead of an HSA?

11. Can the HSA lose its favorable tax status?

12. Are there other things I should know about an HSA?

Flexible Spending Account (FSA)

13. What is a flexible spending account (FSA)?

14. If my employer offers a health FSA, what is the advantage to me of participating?

15. Is there any downside to putting pretax dollars in an FSA?

16. How can I estimate how much I should elect to put in an FSA?

17. Can you give me some examples of how I could estimate?

18. Can I use money in my FSA to help purchase insurance on the Exchange?

19. If I have money left over in my FSA at the end of the year, is there anything I can do to avoid forfeiting it?

Health Reimbursement Account (HRA)

20. What is a health reimbursement account (HRA)?

Comparison

21. Is an HSA, FSA, or HRA better for me?

Internet Sites

22. Where can I find help on the internet?

CHAPTER 18

HOW YOU CAN NEGOTIATE YOUR MEDICAL COSTS AND BILLS

Big Savings Can Be Possible Both Before And After You Incur Medical Expenses

Questions answered in this chapter--

1. Even if you have health insurance or other coverage, it is still important to try to save money; if you don’t have health coverage it is essential.

2. Who is the single most important person to help me lower my medical costs?

3. Can I discuss with my doctor or hospital ways in which my medical costs can be reduced before I have the expense?

4. If I already have a bill from a doctor or hospital, can I negotiate with them to reduce it?

5. What if I don’t feel comfortable raising these issues with my doctor’s office or the hospital?

6. What are good ways to discuss these concerns with my physician (or other medical professional)?

7. If I am concerned about procedures or expenses at a hospital who should I talk to there?

8. Can I save money by having a procedure at a free standing facility, rather than a hospital?

Internet Sites

9. Where can I find help on the internet?