Health Insurance Domain

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Health Insurance Coverage

Health insurance policies are contracts between you and a health insurance company. A list of benefits that are coverby the policy will be provided with your health insurance policy. Benefits could include medication, treatment, testing, 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 extremebroad with a high dollar amount for maximum benefits.

The following items are often covered by major medical insurancepolicies

!ab services

"#$ays

%iagnostic tests including &$'s and (AT#scans

Ambulance services

$adiology

Blood )and plasma*

+xygen

'ntensive care and other hospitaliation )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 WorksPrivate health insurance helps people make sure they will be provided access to health care. Insurance also gives heacare companies assurance that their patients can afford the services and the bill will be paid in a reasonable amount of tim

Health insurance protects consumers from the potentially extreme cost of medical care. If you become extremely ill, the cocan be financially overwhelming. Health insurance helps make sure that doesn't happen to you. Health insurance makehealth care more affordable, predictable, and manageable since the risk of expensive health care needs is pooled across

large group of people.

Many of us cannot afford the risk of not having health coverage. Health insurance is costly, but the expense from evenminor incident or illness can easily deplete your savings and can even leave you financially ruined.

Who Provides Health Insurance? Licensed Health Insurance Providersoth publicly traded health insurance companies!owned by stockholders" and mutual health insurance companies!ownby the policyholders" are licensed health insurers. lue #ross and lue $hield companiesare also state licensed insure%hese programs began as non&profit organiations under state hospital ! lue #ross" and state medical !lue $hieorganiations.lue #ross lue $hield organiations are now !with few exceptions" normal commercial health insurancompaniesusing thelue #ross lue $hieldname.

Health Insurance Companies

Below is a comprehensive list of the health insurance companiesoperating in each state.

Alaska

(eltic 'nsurance (ompany

/olden $ule

Alabama


0ortis

/olden $ule
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Arkansas


/olden $ule

American &edical 1ecurity !ife 'nsurance (ompany

Arkansas Blue (ross and Blue 1hield

Arizona

Health -et of Ariona

(eltic 'nsurance (ompany /olden $ule

acifi(are of Ariona


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


4/18


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

(eltic 'nsurance (ompany Humana

!entuck"

Anthem Blue (ross and Blue 1hield

Humana

#ouisiana


0ortis

Humana


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Blue(ross Blue1hield of !ouisiana

Mar"land


/olden $ule

Aetna

2aiser ermanente

Michigan American &edical 1ecurity !ife 'nsurance (ompany


/olden $ule

0ortis

Blue (ross Blue 1hield of &ichigan

Humana

Minnesota

Blue (ross and Blue 1hield of &innesota

Healthartners

&edica of &innesota

Missouri

Blue(ross Blue1hield of &issouri


/olden $ule


Blue(ross Blue1hield of 2ansas (ity

Humana

Mississippi


/olden $ule

Montana (eltic 'nsurance (ompany

0ortis

$orth Carolina



0ortis

$orth Dakota

0ortis

$ebraska Blue(ross Blue1hield of -ebraska


/olden $ule


$ew Hampshire


$ew %erse"

Horion Blue (ross Blue 1hield of -ew 6ersey


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+ennessee


/olden $ule

Blue(ross Blue1hield of Tennessee


Humana

+e&as

(eltic 'nsurance (ompany 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 companithroughout every state in the nation as well as uerto $ico, 6amaica, anama, and 4ruguay. These companies aindependent franchises that address the health needs of each particular area )usually a state or territory* for which thewere designed.


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1ome companies use only the name Blue (ross Association and others use only the name Blue 1hield Association, bmost independent companies are part of the Blue (ross Blue 1hield Association. Blue (ross and Blue 1hield is Americaoldest and largest independent health insurer. However, the company actually arose from two simultaneous, bseparate solutions for the health care of workers8 organiations.

+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 %allaTexas, developed a health plan that guaranteed teachers ;9 days of hospital care for indicating hospital care for its members. 'n 9:>:, a (hicago#based organiation, American Hospital Association, begusing the Blue (ross symbol to signify that certain standards were being maintained across the country. 'n 9:=@, ttwo organiations merged under the name the Blue (ross Association. The two organiations remained affiliated un9:;.

'n 9:9, in the acific -orthwest, particularly in the mining and lumber camps, an organiation known as ierce (oun&edical Bureau of Tacoma, 7ashington )now known as $egence Blue 1hield* was founded. The concept behind this plawas that members would pay monthly fees to a medical service bureau composed of groups of physicians. The ideuickly spread, and in 9:>:, (arl &etger in Buffalo, -ew Cork created the D1hield 1ymbolE. The shield represented tgroup of doctors who were participating in the medical care program. 4sing the shield symbol, the first official Blu1hield plan was founded in (alifornia in 9:>:. At that time, it was called the Associated &edical (are lans, but wsoon 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 cagiver* coverage, the two companies merged in 9:F;, after years of a mutually enforcing, but often competiticoexistence. The Blue (ross Blue 1hield Association is now a network of independent, locally operated insurancompanies that together insure about one in every four Americans. The B(B1 Association encompasses the fspectrum of health care services including referred rovider +rganiations )+*, Health &aintenance +rganiatio)H&+*, rescription &edication 1ervices, &edicare 1upplemental (overage, and &edicare art %)rescription Assistanrograms*. 1ome states provide %ental (areand 3ision (are rograms.
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/lue Cross /lue *hield Companies

Almost every state has community#based programs, many of which are free, to aid in health improvement amaintenance. &any states have incorporated programs that are free to all schools to assist in dealing with thincreasing problem of childhood obesity. &any states also offer free, or low cost medical help, such immuniations for medically underserved children. Almost all states offer specific programs for prevention and ca

for medical problems that are uniue 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 managcare plansalso 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 specifyingnetwork of health care providers, managed care planspermit insurers to influence the treatment options of their clienIncluded in this category are Health Maintenance )rganiations !HM)",Preferred Provider )rganiations !PP)",and Poof $ervice !P)$" plans.

Individuals covered by a HM) plan must get prior approval from their primary care doctor before getting any type specialied treatment.

HM( )lans 0Health Maintenance (rganizations1

HMO plansare a kind of managed care health insurance plan. HMO planshave a contract with doctors and other heacare 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 morestrictive. These usually have a deductible but no coinsurance reuirement.

&ost HMO plansreuire that a primary care physician )(* be designated by recipients. That physician is the gatewato all health care providers. 'f a HMOcustomer tries to visit a medical practitioner with no a referral from the (, thvisit 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 planhas contracted with to provide services

HMO plansand + plansuse management controls such as the ( limitation and a focus on preventative care lower the cost of healthcare.
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HMO planmembers pay a monthly premium regardless of their medical needs. 'n return for the premium, HMO plaprovide various medical services, from checkups to surgery. &edical services are normally only paid for if the persouses a provider in the HMOnetwork and goes through their (. -etwork sies vary widely, so be sure to check the liof health care providers in your area.

Advantages of HM( )lans Disadvantages of HM( )lans

)reventative CareHMO plansencourage members to seek medical treatment earlyand to have annual checkups. They are focused on wellness and

many HMOsoffer information to their members about stayinghealthy.

)rimar" Care )h"sician atewa"1pecialied medical attention can be more difficult tobtain with an HMO plan. The ( is the access to a

health care services you canGt see a specialistwithout a referral. This helps the health insurancecompany reduce expenses for its HMOmembers anthe company.

#east 2&pensive Health InsuranceThere is usually not a coinsurance reuirement with HMO plans.'nstead of a deductible, most HMO planshave small co#payments for medical services and treatments. 1o, regardless ofyour medical needs, a HMO planwill probably just charge youthe monthly premium and a small co#payment.

$o Coverage for (ut3of3$etworkHMO insurancewill probably not cover a visit to adoctor who is not in the HMOnetwork, even if thereare no network providers in the area.

$o #ifetime Ma&imum )a"out4nlike other health insurance plans, many HMO policiesdo nothave a lifetime maximum payout. They will pay for your medical

needs as long as you are a member.

*trict definitionsThe definitions for HMO planstend to be limited. 0o

example, an emergency room visit may only be

covered if it meets the companyGs definition of anemergency, which could be surprisingly restrictive.

#ess complicated billingBilling systems for HMOsare usually less complex than otherprograms, so customers experience less problems.

More difficult to change docto&any HMOsdiscourage you from changing primacare physicians. Cou may be limited to changing yoprimary care doctor once or twice.

)atient 4uotahysicians who participate in HMOs are oftreuired to see a minimum number of patients eveday. This could limit the time your doctor can spenaddressing your needs. 1ome doctors receive particular amount from a HMO planregardless of tnumber of patients they see, making it preferable f

the doctor to have less appointments.

+ests&any HMOs reuire that diagnostic tests approved before they will be paid for. This coudelay your health care treatment.

))( )lans 0)referred )rovider (rganizations1

As managed caresystems, PPO plansare very similar to H&+ plans. PPO plansprovide health care for their membeby contracting with selected hospitals and doctors. &any PPO programswill cover non#network providers if you pay

larger co#payment or deductible.

.hat is ))( Health Insurance5

A ))( is a roup of Doctors

%octors within the PPOnetwork only provide care to a specific group. The PPOmay be sponsored by a health insurancompany, an employer, or a group of employers. The health insurance group trades the increased patient number fordiscounted rate from the health care provider.

))( )lans are 6eimbursement )rograms
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7ith a PPO health insurance plan, you will probably pay for your health care services and be reimbursed by the heainsurance company. +ften the doctor will send the bill to the health insurance company for you. The reimbursement thyou or you doctor get will depend on the policyGs co#payment and deductible, which are subtracted.

Advantages of ))( )lans Disadvantages of ))( )lans

Choice of doctorPPOnetworks tend to be much bigger than H&+ networks.'f you do see a non#network provider, the majority of PPOplanswill 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(PPO plansare generally more expensive than H&+ heainsurance plansas a result of the flexibility they offer.

$o )rimar" Care )h"sician atewa"Cou probably will not have to designate a ( or obtainreferrals before you can visit a specialist if you are amember of a PPO.

More paperwoPPOsoften reuire more paperwork than comparable H&plans. (ustomer service and billing problems are oftmore freuent with PPO plansas well.

/etter Coverage for Chronic Conditions and $on3traditional Medicineeople with chronic conditions such as back pain, allergies,and arthritis tend to be more satisfied with PPO plans. APPO could also cover non#traditional treatment such aschiropractic care or acupuncture.

)oint3of3*ervice 0)(*1 )lans

Point-of-service plansaremajor health insurance plansthat bring together characteristics of both H&+ plansand plans. They are more flexible than H&+s, but they do reuire 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 plansnormally cover a portion of charges from out#of#network providers, but it will bless than if an in#network provider is chosen. POS health insurancecompanies will usually make an exception if yo( 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 havedeductible.

Advantages of )oint3of3*ervice )lans Disadvantages of )oint3of3*ervice )lans

Choice of Doctor'f you see a non#network provider, most POS planswill stillpay a percentage of the cost )it will be less than they wouldpay for an in#network provider unless you obtain a referralfrom a (*.

)rimar" Care )h"sician atewThe ( is the gateway to all health care services. CwonGt get complete coverage for a specialist withoutreferral. However, unlike an H&+ plan, the POS plan wprobably pay a portion of the cost even if you donGt obtaa referral.

*mall Co3)a"ment7 no DeductibleThe majority of point-of-service plans have small co#payments for medical services and treatments instead of adeductible. There is normally a deductible and bigger co#payment for non#network care however.

More 2&pensive than HM(Point-of-service plans tend to be more expensive thH&+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 continugroup health insurance coveragethat might otherwise be terminated. (+B$A is not an insurance plan or company, it a law. (+B$A health insurance provides retirees, some former employees, spouses, and dependant children the right

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 actiemployees since employers usually pay part of health insurance premiums. However, it is usually less expensive thindividual health insurance.

Details of C(/6A Insurance
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(+B$A health insurance applies to plans in both private sector as well as those sponsored by state and locgovernments, provided previous health plans in the prior year were maintained by twenty or more employees. /rohealth insurance plansare defined as plans utilied by employers in order to provide medical benefits for employees antheir dependants through insurance or otherwise.

(+B$A defines some of these alternative plans as trusts, health maintenance organiations, self#funded pareimbursement, or a combination. (+B$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$A, after termination of employment, you have sixty days after to decide whether or not to take advantagof continued health insurance coverage. The employer will ask that you pay for the premium on the health insuranplus a ; surcharge. +btaining (+B$A health insurance allows you to continue using the same benefits as under thprevious employer8s health insurance plan. eople under the program receive the same benefits as current employeso 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 acuired 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,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 reuiring 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.
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Above two are the most common plans, but one new plan has been introduced in 6an ;@@= is &edicare a

%, which is a %$4/ 'nsurance plan. +nly the people having either &edicare art A or B are eligible to talan %.

Cou can choose different ways to get the services covered by &edicare. %epending on where you live, yo

may have different choices. 'n most cases, when you first get &edicare, you are in the +riginal &edicalan. Cou may want to consider a &edicare rescription %rug lan to add drug coverage. +r, you may wato consider a &edicare Advantage lan )like an H&+ or +* that provides all your art A, art B, and ofteart % coverage. Cou make a choice when you are first eligible for &edicare. 5ach year you can review yo

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 y

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 a

inpatient services to people in rural areas*, skilled nursing facilities )not custodial or long#term carehospice 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 payme

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 enou

&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 the

covered medical services and items when they are medically necessary. art B also covers some preventiservices.

Medicare is changing%he Medicaresystem is 0uickly changing and the information here is intended for people who are already 12 years of ag

3ounger people should note that Medicarewill 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 Medicaprogram began in 4512 and is funded by both federal and state governments.

Medicaidmay be a good option for seniors who live on a fixed income and cannot afford to obtain the health care they nee-dditionally, the Medicaidprogram can provide nursing home, adult daycare, and other long term care coverageto peopwho meet certain eligibility criteria.Medicaidbeneficiaries do not need Medigap coveragesince Medicaidwill pay for their health care expenses. Individuawithin 4678 of the poverty line are eligible for coverage that will pay their Part premiums.

Medicare Supple"ent Insurance

$ince Medicaredoes not cover all health care expenses, Medicare supplement insuranceis sold as supplemental heainsurance forMedicare recipients. %here are a number of gaps in Medicare coverage, so this Medicare supplemeinsuranceis often known as Medigap.Medicare supplement insurance is not a federal program like Medicare. -lthough health insurance companies proviMedicare supplement insurancecoverage, they are strictly regulated by both the federal and state government.

Medicaidbeneficiaries do not need Medicare supplement insurancecoverage because Medicaidwill pay for their heacare expenses. Individuals within 4678 of the poverty line are eligible for coverage that will pay their Part premiums.

$ee the section onMedicarefor more information onMedicarePart - and .
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%he ma9ority of Medicare recipients purchase Medicare supplement insurance. %he :$ has standardied all Medicasupplement insurance plans. %here are 47 types of Medicare supplement policiesavailable.

e0uired benefits under any Medicare supplement insurance plan(

12 hospital days beyondMedicarecoverage !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"entsIn the first 1 months that someone is eligible for Medicare, they must be accepted to any Medicare supplement insuran

policybeing offered at that time.

Medicare supplement insurancecompanies 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


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How can individuals obtain drug coverage5 5ligible individuals can obtain &edicare prescription dr

coverage from the following sources

1tand#alone prescription drug plans # 'ndividuals in traditional &edicare or enrolled in private plans that are n

reuired to provide prescription drug coverage )such as &edical 1avings Account plans or private fee#for#serviplans* 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

&edical 1avings Account plans or private fee#for#service plans that offer drug coverage ## must obtain their drcoverage from their plan. )&edicare H&+s and + are reuired to provide &edicare drug coverage along witraditional &edicare benefits.*

5mployer#sponsored plans # 'ndividuals eligible for employer#provided retiree health coverage can receive theprescription drug coverage through such plans.

+ther sources # 'ndividuals currently enrolled in &edicare cost contracts or A(5 programs that elect to provid

prescription drug coverage can obtain their drug coverage through such plans. &edicare cost contracts amanaged care plans that are reimbursed on a cost basis by the &edicare program. A(5 )rogram of A'nclusive (are for the 5lderly* programs are programs of comprehensive care that allows frail elderly people live in their communities.

0ederal fallback plan # The new law guarantees that individuals will have a choice of at least two prescription drug pla)at least one of which must be a stand#alone drug plan*. 'f less than two drug plan options are available in an area, thgovernment 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 insuranpoliciespay the provider directly. There is often a maximum benefit amount per year.

&any orthodontic and other special needs trigger a coinsurance reuirement in dental insurance plans. &any routiappointments, cleanings, and x#rays do not reuire coinsurance contributions.

5mployers support nearly all dental insurance plans. Individual dental plansare hard to find, so many individuals wpurchase a dental discount planin 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 plansare membership based programs with enrollment fees and monthly charges.

Dental discount plansare unregulated.

Dental discount planscan 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 insurancefie

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

accepted.

-etwork sie for dental discount planscan be extremely limited. Be certain that there are providers in your are

and be aware that the providers may revoke their membership in the dental discount planat any time.

1ome dental discount plansoffer discounts on cosmetic procedures not covered by dental insurance.

Dental Insurance

Dental insurancehas premiums, co#payments, and deductibles.

After the deductible is met, all costs are covered, up to the annual maximum benefit.

Dental insurance policiesare only sold by licensed professionals.

Dental insuranceis 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*


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Treatment of gum diseases and other periodontal tissues

+rthodontics )braces, retainers, etc.*

-ision Insurance Coverage

.hat Does -ision Insurance Cover5

Vision insurancecovers care and treatment for your eyes. These plans often cover annual eye exams, glasses, contactand glaucoma screening. !aser eye surgery is even covered with some vision plans. Vision Insurancecan be extreme

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 insurancecompany to reimburse you late+ther plans pay the eye care provider directly.

Vision insuranceis not a substitute for health insurance. 'n fact, most often a medical problem discovered by your eydoctor )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 insurancecould help you get a discount on the glasses or contacts that you need anywa&any vision insurance plansare supported by employers, but if youGre looking for a vision planon your own, sharound and compare the cost and benefits offered with each plan.

Health Insurance ost onsiderations

%educti&les' o(Pay"ents' and oinsurance3ou will nearly certainly pay a deductible before the health insurance plan will chip in for your health care. %his is usually 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 =


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5ducation and $esearch, and (o#chair of the 7orkgroup for 5lectronic %ata 'nterchange )75%'* -' +utreach 'nitiativThis tool is intended for educational purposes only. 1hould you or your company have specific uestions on how comply with the -' reuirements 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 largprovider organiations. The 9@#digit '% is Dintelligence#freeE in that it does not have any coded information embeddinto it, nor does it communicate specific characteristics of the health care provider it identifies. 'ndividual providers sucas physicians, dentists, nurses, chiropractors, and therapists

will be able to obtain only one -' for themselves. rovider organiations such as hospitals, medical or dental groupractices, nursing homes, pharmacies, and laboratories, will be able to obtain one -' for the organiation and one -for specific components of the organiation )known as D1ubpartsE*. +nce assigned, the -' of a provider will not chang't will remain the same regardless of change in location, scope of practice, or any other factor, except in certacircumstances such as when an individual provider retires, an organiation provider ceases to exist, or a provider8s -is being used fraudulently. The -' is reuired to be used as the only identifier for health care providers that arelisted and reported in H'AA standard transactions. H'AA standard transactions include health care claims, clapayments, eligibility, and referrals. Health care providers generally listed in these transactions include the billingJpay#

provider, rendering provider, referring provider, attending physician, and operating physician.

.hat is the $ational )rovider Identifier

A H'AANmandated national standardO 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 organiationsO +ne -' per individual providerM one or more -'s to uniuely identify an organiational provider and its subpartsO ermanently assigned, and not expected to changeO $euired 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 uniue identifier for each provider, rather the variouhealth plan#specific identifiers currently in use. The -' will replace all other provider identifiers used in H'AA standatransactions, 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 plaand clearinghouses when submitting and receiving H'AA standard transactions.The -' will facilitate the process of coordinating benefits )(+B* across health plans, by having (+B transactiocontain 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#speciidentifiers )such as

&edicare8s 4'-, &edicaid provider '%s, private health plan provider '%s* will be replaced by -' O 1implify providbillingO 0acilitate conducting coordination of benefits

The -ational rovider 'dentifierAll entities covered by the H'AA !aw are reuired to comply with the -' regulations. (overed entities must be able accept -'s and process information using -'s.

(overed entities include all health plans )including &edicare, &edicaid, and private insurance plans*M all clearinghouse)companies that receive, process, or facilitate the processing of health care transactions between providers and healplans from a nonstandard format into a H'AA standard format, or vice versa*M and health care providers that transmhealth 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 -'. +nthose health care providers that are covered by H'AA are $5P4'$5% to obtain and use their -'s. A health caprovider is defined in H'AA regulations as a provider of services )a hospital, critical access hospital, skilled nursinfacility, comprehensive outpatient rehabilitation facility, home healthagency, hospice program*, a provider of medical or health services )physician services, certified nurse#midwife serviceualified psychologist services, clinical social worker services*, and any other person or organiation who furnishes, bilor is paid for health care in the normal course of business.

.ho is *ubject to Compl" with the $)IO All Dcovered entitiesE are reuired to comply with the -' regulations N (overed entities include health planclearinghouses, and health care providers that transmit administrative transactions electronicallyO All health care providers are eligible to obtain an -' O (overed health care providers are reuired to obtain and utheir -'s


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The -ational rovider 'dentifier&ost individual health care providers that are identified in transactions )for example a physician being reported as threndering provider in a professional claim or the attending physician in a hospital claim* will need to have their owindividual -', which will need to be reported in the appropriate location in the claim transaction.An organiational health care provider that conducts transactions electronically and is the legal entity billing for healcare services must obtain an -' for its own use.The legal organiation may also choose to obtain separate -'s to identify components )known as 1ubparts* of thorganiation. 0or example, a hospital may choose to identify one of its units, the $ehabilitation 4nit, with an -' that

different from the hospital -'. There are certain conditions that subparts must meetO 1ubparts cannot be a separate legal entity from the DparentE organiation.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 organiation or have the same taxonomcode as the parent organiation.O D1ubpartingE is an option, not a reuirement )except when the subpart conducts its own transactions, separate frothe parent organiation, +$ when the subpart would be a covered health care provider if it were a separate legal entitin these two cases the subpart &41T obtain an -'*.

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