| HMO |
| Health Maintenance Organization, gatekeeper required with directory of physician and hospitals for In-network benefits, NO out-of-network benefits. Some HMO plans do not require referrals from a gatekeeper or PCP to utilize In-network specialists. |
| POS |
| Point of Service, gatekeeper required, with directory of physician and hospitals for In-network benefits, includes out-of-network benefits after satisfaction of a deductible and coinsurance. |
| POS-Open Access |
| Open Access- Same as POS above, however no referrals are necessary to utilize In-network specialists. |
| PPO |
| Preferred Provider Organization, NO gatekeeper necessary, may go to any physician in the network without a referral, includes out-of-network benefits after satisfaction of a deductible and coinsurance. |
| EPO |
| Exclusive Provider Organization, NO gatekeeper or referrals required. In-network benefits only. NO out-of-network benefits. |
| STD |
| Short Term Disability is defined as an absence from work due to an accident or sickness that occurs outside the work environment (all on-the-job accidents are covered through Workers Compensation). A typical STD policy will provide an employee with a weekly portion (e.g. 50% or 60%) of their salary to a pre-determined "cap" (e.g. $5000 or $10,000) for a pre-determined length of time (e.g. 13, 26, 52 (max) weeks).
According to the American Council of Life Insurers, nearly one-third of all Americans will suffer a serious disability between the ages of 35 and 65. |
| LTD |
| Long Term Disability resulting from a non-occupational accident or sickness is available to firms who have been in business at least two years. Benefits are available up to 60% of salary with a usual maximum of $5,000 per month. Waiting periods can be 90 or 180 days and benefit periods can run as short as two years or to age 65. |
| DBL |
| Statutory Disability Benefits is mandatory for all New York State corporations. DBL is designed to provide temporary cash payments to a worker if he or she is disabled OFF THE JOB by an accident or illness that does not arise out of or in the course of employment. The circumstances that DBL is paid under are; to a disabled actively employed worker to partially replace wages lost during a period of disability, or to an unemployed worker to partially replace unemployment insurance benefits lost because of illness or injury.
Weekly cash benefits equal 50% of a claimant's average weekly wage, to a maximum cash benefit of $170.00 per week. There are plans that provide benefits in excess of the statutory minimum. These would include higher minimum weekly benefits and higher benefit percentage. Benefits can be paid for up to 26 weeks of disability during any consecutive 52 week period. For employed workers, there is a seven-day waiting period for which no benefits are paid. On the 8th day, benefits for employed workers begin. These benefits are subject to Social Security and withholding taxes. |
| Group Life and AD&D |
| Group Life and AD&D is available either as a flat amount or a schedule based on salary. InsuranceNY has available plans that can be written down to 2 employees. Please note that states with community rated health insurance programs tend to have the most undersold ancillary benefits. With today's prices, these benefits have never been a better value.
InsuranceNY also offers individual life insurance. |
| Long Term Care (LTC) |
Long-term care is the type of insurance you or someone in your family may need if you no longer can take care of yourself, for example, if you needed assistance getting dressed, eating or bathing.
What would my family do today if I needed some type of long-term health care?
Would they be able to care for me at home?
What if I needed nursing home care?
How would we pay for all of this?
In order to help ensure financial security, you must begin to plan today. Most people do not begin until it is too late. Long-term care insurance can help secure not only your financial future, but also that of your family and loved ones. A long-term care insurance policy can help protect your assets from the rising cost of care, allowing you to remain financially and socially independent. |
| HSA, HRA, FSA, Section 125 |
| 2005 brings a new option for health insurance and health savings accounts, a combination of High Deductible Health Plans (HDHP) and Health Savings Accounts (HSA). The first part of the combination, a High Deductible Health Plan, is an insurance policy or self-funded plan that covers catastrophic medical expenses. The second part, the Health Savings Account, is a banking and/or investment account from which the member can withdraw money tax-free to use for qualified medical expenses. Unused funds accumulate tax-free until retirement, when an individual can withdraw for any purpose and pay normal income taxes. |
| COBRA |
| The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102 percent of the cost to the plan. Former Employees can change benefits under COBRA during open enrollment - A former employee or his or her dependent may choose any health benefit plan available to active employees during open enrollment. Each member is treated separately and may, if he or she wishes, choose different coverage. When enrolled under COBRA, each member is treated the same as an active employee with respect to changing coverage. COBRA and Medicare coverage - An individual who is already enrolled in Medicare or who is Medicare-eligible and then becomes eligible for COBRA, can still elect and enroll in COBRA while also having Medicare coverage. However, COBRA coverage ends for individuals who are already enrolled in COBRA and then become eligible for Medicare (unless eligible due to End Stage Renal Disease (ESRD). Individuals who have COBRA and become Medicare-eligible should enroll in Part B immediately because they are not entitled to a Separate Enrollment Period (SEP) when COBRA ends.
|
| What is the difference between PPO and POS/NGP? |
| All Hospitals in a PPO network are considered In-Network no matter who admits the insured. Admittance to a Hospital, can be made by a Participating provider or a Non Participating provider. In a POS/NGP, for the hospital to be considered IN-Network, only a Participating provider may admit an insured to the hospital. |
| What is a Gatekeeper or Primary Care Physician (PCP)? |
| A gatekeeper (PCP) is utilized under HMO and POS plans. This is the primary care physician of the insured. The insured is responsible to secure all referrals to a specialist, from their PCP. |
| What is a Co-pay? |
| The amount of money the insured must pay to the In-network doctor, the insured's cost sharing of the treatment. |
| What is a Deductible? |
| The initial amount the insured pays before any reimbursement is made for out-of-network procedures. This applies to all POS, POS/NGP and PPO plans. |
| What is co-insurance? |
The amount the insured must pay in addition to what the insurance company pays. It is the sharing of the cost of medical care.
Example when an insured goes to an out of network doctor: After the insured deductible is met; if the insured has 70/30 co-insurance, the insured would pay 30% of the cost, up to the stop loss. |
| What is Stop-Loss? |
The maximum amount the insured would pay.
Example: If the insured has a 70/30 of 5,000, the maximum amount the insured would pay under co-insurance is 30% of $5,000 or $1,500. |
| What is a UCR level? |
| UCR stands for usual and customary reimbursement for a particular geographic area. |
| What is the difference between 2 and 4 tier rates? |
| Two tier rates are based on Single/Family combinations and any one enrolling other than Single will pay the family rate. Four tier rates have a combination of Single / Parent & Child(ren) / Employee & Spouse / Family. Rates for four tier are based on the status upon enrollment and offer lower rates for the two middle tiers, while being higher for the family. |
