2012

Immune Deficiency Foundation Health Insurance Toolkit for Patients with Primary Immunodeficiency Diseases and Their Families

September 2012

IDF Health Insurance Toolkitfor Patients with Primary Immunodeficiency Diseases and Their Families

Having the tools you need to select the right healthcare plan for you and your family is very important. As the U.S. healthcare system undergoes changes, one important change is that individuals and small businesses will be able to shop for and purchase health insurance through a state insurance exchange. Those affected by primary immunodeficiency diseases (PIDD), as well as other rare disorders, need to make educated decisions on their coverage options. The Immune Deficiency Foundation’s (IDF) Health Insurance Toolkit provides you with the information and resources to make the best possible choice in selecting a private health insurance plan.

This toolkit reflects rules and protections already in place under the Affordable Care Act, including no cost-sharing for certain preventive services and a ban on lifetime limits on benefits. Changes that take effect in 2014 will be reflected in the next, updated edition of the Health Insurance Toolkit and will include a ban on annual limits on benefits, the essential health benefits and standardized levels of coverage.

It is essential to understand your family’s current utilization of healthcare and learn to evaluate and compare medical insurance plans available in your area. The selection of an appropriate insurance plan can affect the health and finances of both the patient with primary immunodeficiency disease and family members. IDF is proud to offer this toolkit to provide you with information, facts, resources and worksheets to help you choose the best possible options for you and your family.

About the Immune Deficiency FoundationThe Immune Deficiency Foundation (IDF) is the national non-profit patient organization dedicated to improving the diagnosis, treatment and quality of life of persons with primary immunodeficiency diseases through advocacy, education and research. IDF was founded in 1980 by parents of children with primary immunodeficiencies and their physicians. At that time, there were few treatments for primary immunodeficiency diseases, almost no educational materials for patients, no public advocacy initiatives, and little research being done. In the past thirty years, IDF has pursued an aggressive agenda to remediate these problems and has made tremendous strides in the following areas:

Helping the patient and professional communities gain a broader understanding of primary immunodeficiency diseases through comprehensive education and outreach efforts;

Promoting, participating in, funding and supporting research that has helped characterize primary immunodeficiency diseases and given healthcare providers substantially improved treatment options for the care of patients with primary immunodeficiency diseases;

Addressing patient needs through public policy programs on local, national and international levels by focusing on issues such as insurance reimbursement, patient confidentiality, SCID newborn screening, preventing genetic discrimination, ensuring the safety and availability of immunoglobulin therapy, and maintaining and enhancing patient access to a full range of treatment options;

Establishing supportive networks of patients and professionals to ensure that the needs of patients with primary immunodeficiency diseases are recognized and addressed.

In the United States, approximately 250,000 people are diagnosed with a primary immunodeficiency disease, and many more go undetected. Representing a group of more than 150 different rare disorders, primary immunodeficiencies are often difficult to diagnose. While not contagious, these

IDF Health Insurance Toolkit - 2

diseases are caused by hereditary or genetic defects, in which part of the body’s immune system is missing or functions improperly. These individuals live throughout the country and experience a number of problems which have been documented by IDF. These patient problems include:

Difficulty in finding specialized healthcare by immunologists or care providers knowledgeable about immunodeficiency

An inordinate delay in reaching proper diagnoses Problems with availability of appropriate treatment Difficulties financing healthcare and treatment Finding instructional materials about the specific diseases Educating the community and those with whom they come in contact about their disease

and particular needs Lack of peer support and connection to others with whom they can share experiences

The goal of IDF is to address these issues and help affected individuals to overcome these difficulties, thereby enabling them to live healthy and productive lives.

For more information, contact IDF: 800.296.4433 or www.primaryimmune.org.

Table of Contents

Private Health Insurance Toolkit………………………………………………………………………….5Provides a general overview of the toolkit

Getting Started………………………….……………………………………………………………………6Identifies what materials you need to complete the Health Plan Cost Comparison Worksheet

Personal Health Experience Status Sheet………………………………………………………………7Allows you to summarize your healthcare utilization in order to understand your needs in choosing a new healthcare plan

Health Plan Cost Comparison Worksheet …………………………..………….………………………8Helps you record and compare healthcare plans’ cost and benefits

FACT SHEETS

Summary of Benefits and Coverage (SBC) and Uniform Glossary……………………………….12Standard forms that must be used by all health insurance companies to summarize benefits and coverage.

Prior Authorizations…………………………………………………………………………………….....13Information about prior authorizations required for certain procedures and medications

Appeals & Grievances………………………………………………...…………………………………..14If you are denied coverage of healthcare claims, this section will help you understand the appeals process.

Medicare.……………………………………………………………………………………………………16Summary of how Medicare eligibility affects those with private insurance coverage

Acronyms and Glossary………..……………………………………..………………………………….20

This publication will be updated periodically. Please visit the Immune Deficiency Foundation website for updated versions at www.primaryimmune.org.

Private Health Insurance Toolkit

Whether it is an individual or family policy offered through your employer (a group health plan) or one you acquired as an individual, there are many things to consider when reviewing your options. These considerations usually fall under one of two categories: cost or benefits. Typically most people look at the cost of the plan when making a decision – our goal is to help you evaluate the benefits you receive in relation to the cost of the plan you select. Questions to ask may include:

What is the monthly/annual premium for the plan? In a given year, what might be the sum total of my out-of-pocket costs, including medical and

prescription co-pays, deductibles and/or co-insurance? Will the policy cover all the services I need? Are my physicians covered or are they out-of-network? Are there annual limits? If so, is it a maximum annual benefit limit based on dollars or on

number of visits or both? For example, home healthcare coverage is usually limited to a certain number of nursing visits per year.

Are out-of-network benefits available? If so, what percentage of cost will be my responsibility if I receive out-of-network benefits?

Am I covered if I get sick while out of state? Out of the country?

For those affected by primary immunodeficiency disease, there are often additional, more specific, questions you must ask that relate to what benefits are covered and how, such as:

Is immunoglobulin (Ig) therapy covered? If so, is it a part of major medical or a pharmacy benefit?

Do I have a choice of site of care (hospital, home infusion, physician’s office)? Do I have a choice of administration of therapy, i.e. subcutaneous (SCIG) or intravenous (IVIG)? What is my out-of-pocket cost for my Ig therapy? Are supplies and nursing services covered? Do I need a referral to see a specialist? What services require prior authorization? Is Ig therapy subject to a restrictive formulary? Will I be required to switch from my current Ig product to another product? Does the plan provide a case manager to assist me with navigating my benefits?

Answers for many of the questions above, both relative to cost and benefits, can be found by reviewing your plan’s summary of benefits, drug formulary list and provider network directory. While this is often viewed as a tedious process, it is one of the most important steps you can take to insure that a plan meets your needs.

It is important to remember that …Once you choose a plan, you cannot change until the next open enrollment period.

In many instances, you may find that you have the option to choose between multiple plan types and designs: HMO, PPO, POS, EPO, etc. The “Health Plan Cost Comparison Worksheet” (page 8) is a tool designed to assist you in performing a side-by-side comparison of your plan options by helping to identify coverage benefits and out-of-pocket costs associated with each. The Worksheet can be used in two ways: as a tool to make general comparisons between health plans or as a customized tool designed to highlight the costs and benefits specific to your individual needs.

Getting Started

Step 1Prepare the “Personal Health Experience” status sheet (page 7).

Step 2Collect from your Human Resources representative, case manager or navigator the following documents for each health plan being presented. Alternatively, if you are purchasing individual insurance, ask for the plan documents from the insurance company or insurance broker. (Please note that often you will be provided with a link to this information on the carrier’s website.)

1. Benefit Summary - A benefit summary gives an overview of the benefits provided by health insurance plans and does not include all requirements or qualifications of each benefit. It shows current rates for all benefit programs including health, dental and life insurance. It is only a document given for informational purposes and does not constitute an agreement.

2. Drug Formulary - Health insurance companies maintain a formulary, which is a list of prescription drugs, both generic and brand name that are available through your health plan. A formulary classifies drugs into different cost tiers—categories that define the plan member’s co-payment or co-insurance levels. Prescription drug plans financially reward patients for using generic and lower-tier formulary drugs by requiring the patient to pay progressively higher co-payments or co-insurance for drugs on higher tiers.

3. Provider Network Booklet - A provider network is a group of providers (such as physicians, pharmacies, hospitals and others) who are contracted to provide healthcare services to plan members. These providers have agreed to see members under certain rules, including billing at contracted rates. To get that price, a patient must be covered by a particular health plan that uses that network. A patient has less or no insurance coverage if they see a provider who is out of their network with some health plans.

4. Health Savings Account or Flexible Spending Account - If your employer provides either of these programs, printed copies of the details will be helpful. A Health Savings Account is a medical savings account available to individuals enrolled in a high-deductible health plan that meets certain federal rules for out-of-pocket costs. The funds contributed to an account are not subject to federal income tax at the time of deposit. Healthcare Flexible Spending Accounts are employer-established benefit plans that reimburse employees for specified medical expenses as they are incurred. The employee contributes funds to the account through a salary reduction agreement and is able to withdraw the funds set aside to pay for medical bills.

Step 3Begin using your “Health Plan Cost Comparison Worksheet” by using the information from your benefits summary and drug formulary to fill in each section that applies to your insurance needs on the worksheet. You could use a pencil to make changes or make a photo copy of the worksheet. If the data you need is not available in the information provided to you, call your Human Resources, Benefits Administrator, case manager, navigator or insurance representative.

Personal Health Experience Status Sheet

Choosing a healthcare plan can be very confusing. There are many things to consider, however, two of the most important are cost and benefit design. When trying to determine your potential out-of-pocket costs, it is important to determine which benefits you (and your family, if you are all on the same policy) typically use and how often you use them. This will help you project your out-of-pocket costs for the upcoming benefit year. The easiest way to do this is to ask yourself the following questions:

“In the past 12 months I have…”

Visited my primary care physician _____ times Spent $ _____ in out of pocket costs (OOP)

· Spouse has visited his/her primary care physician _____ timesSpent $ _____ OOP

· Child(ren) have visited their primary care physician _____ timesSpent $ _____ OOP

Been seen by a specialist _____ times Spent $ _____ OOP

· Spouse _____ timesSpent $ _____ OOP

· Child(ren) _____ times Spent $ _____ OOP

Visited an ER or urgent care center _____ times. Spent $ _____ OOP

· Spouse _____ timesSpent $ _____ OOP

· Child(ren) _____ timesSpent $ _____ OOP

Purchased _____ number of prescriptions (including for my family) at my local pharmacy. Spent $ _____ OOP

Been admitted to a hospital for an overnight stay _____ times.· Spouse _____ times · Child(ren) _____ times

Number of immunoglobulin therapy treatments _____Spent $ _____ OOP

This edition of the toolkit reflects rules and protections already in place under the Affordable Care Act, including no cost-sharing for certain preventive services and a ban on lifetime limits on benefits. Changes that take effect in 2014 will be reflected in the next, updated IDF Health Insurance Toolkit publication and include a ban on annual limits on benefits, the essential health benefits, and standardized levels of coverage. For any unfamiliar acronyms or terms, see the Acronyms and Glossary section that begins on page 20.

Health Plan Cost Comparison Worksheet

Healthcare Plans (put name of each plan offered in separate column)

Name of plan1) 2) 3)

Plan Type (EPO, HMO, PPO, POS)

Does plan require you to choose primary care physician Yes □ Yes □ Yes □(PCP)?

No □ No □ No □If so, is your current primary care physician in network?

□ □ □Yes Yes Yes

No □ No □ No □

Premium (this can be monthly, annually or per pay period)

$ $ $

Financial (deductable/coinsurance/annual limits) Note: Some services are covered before deductible is metDeductible:

$ $ $IndividualFamily

$ $ $

Maximum out-of-pocket$ $ $

Individual$ $ $Family

Co-Insurance – out-of-pocket (i.e. 90/10, 80/20, 70/30)/ / /

Is the deductible included in the out-of-pocket?Yes □ No □ Yes □ No □ Yes □ No □

Does the plan have annual max? (for all group plans and new individual policies issued after 3/23/2010, the ACA restricts and phases out annual limits; the limit for 2012 is $1.25 million, unless the plan received a waiver)

Yes □ Yes □ Yes □No □ No □ No □

If so, what is the limit? $ $ $Does the plan have life time max?

Yes □ Yes □ Yes □(no plan may impose a lifetime maximum on benefits thatare considered essential) No □ No □ No □If so, what is the limit? $ $ $

(Worksheet continued on next page)

Preventive Care Co-Pay (For a complete list of preventive services for which there is no co-pay allowed under the ACA, go to http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html.)

Physical exam $ $ $

Routine pediatric care $ $ $

Immunizations (the ACA bans co-pays for recommended $ $ $

vaccines for children up to age 18 and adults)

Osteoporosis screening (the ACA bans co-pays for

$ $ $

women over 60 depending on risk factors)

Gynecological exams $ $ $

Prostate screening $ $ $

Mammograms (the ACA bans co-pays for exams every 1to 2 years for women over 40)

$ $ $

Colorectal Cancer screening (the ACA bans co-pays foradults over 50)

$ $ $

Major Medical

(Do you have a copy of the plan's provider list?)

Yes □ Yes □ Yes □

No □ No □ No □

Out of Network Co-Insurance

Please note cost shares may vary with using out-of-network providers. Indicate plan’s percentage of cost share.

% % %

Outpatient Care Co-Pay (ongoing co-pays after deductible is met)

Physician office $ $ $

Specialist $ $ $

Surgery $ $ $

Laboratory services $ $ $

Immunoglobulin (Ig) infusions $ $ $

Nursing visit ____ visits allowed per calendar year $ $ $

Hospital Care (Inpatient services)

Physician's and surgeon's services $ $ $Private room and board $ $ $Semi-private room and board $ $ $All drugs & medications $ $ $

(Worksheet continued on next page)

Emergency Care Per Visit Co-Pay (for group plans and individual policies created or issued after3/23/2010, the ACA bans higher co-pays or co-insurance for out-of-network ER services)

Emergency room $ $ $

Urgent care center $ $ $

Maternity Care

Pre-natal and post-natal care $ $ $

Hospital services (mother and child) $ $ $

How many post delivery recovery days available

Substance Abuse Co-Pay

Inpatient ___ visits allowed per calendar year $ $ $

Outpatient ___ visits allowed per calendar year $ $ $

Mental Health Co-Pay (The Mental Health Parity and Addiction Equity Act prohibits plans from imposing higher deductibles or co-pays or tighter limits on visits than are allowed for medical services in the plan)

Inpatient _ visits allowed per calendar year $ $ $

Outpatient visits allowed per calendar year $ $ $

Pharmacy Benefits Co-Pay(do you have a copy of the plan's drug formulary list?)

Yes □No □

Yes □No □

Yes □No □

Yearly deductible IndividualYearly deductible Family

$$

$$

$$

Co-pay Tier 1 (generics) $ $ $

Co-pay Tier 2 (Formulary/brand) $ $ $

Co-pay Tier 3 (Non-Formulary) $ $ $Co-insurance Tier 4 (Specialty Tier) - % cost share or co- pay $ or % $ or % $ or %

If your plan has a specialty tier with co-insurance is there a maximum per prescription?

Yes □No □

Yes □No □

Yes □No □

Is there an annual pharmacy maximum out-of-pocket?Yes □No □

Yes □No □

Yes □No □

Is immunoglobulin therapy covered under the pharmacy benefit?

Yes □No □

Yes □No □

Yes □No □

Do you have more than one choice of ‘specialty’pharmacy provider?

Yes □No □

Yes □No □

Yes □No □

Is there a preferred specialty pharmacy?Yes □No □

Yes □No □

Yes □No □

(Worksheet continued on next page)

Other (if offered) (ongoing co-pays after deductible is met)

Chiropractic visits allowed per calendar year $ $ $

Short term rehabilitation – inpatient $ $ $Short term rehabilitation – outpatient _ visits allowed per calendar year $ $ $

Skilled nursing facility (SNF) $ $ $

Home healthcare visits allowed per calendar year $ $ $

Hospice care – Inpatient $ $ $Hospice care – outpatient visits allowed per calendar year $ $ $

Palliative care visits allowed per calendar year $ $ $

Total Estimate of Cost

Summary of Benefits and Coverage (SBC) and Uniform Glossary

Whether comparing health plan options from your employer or shopping for health coverage on your own, benefit summaries will be easier to read and use in choosing or renewing a plan beginning September 23, 2012. Under the Affordable Care Act (ACA), all health insurance companies and employers offering coverage will have to use the same standard form to summarize the benefits and coverage offered under the plan. With each insurance company and employer using the same form, consumers can more clearly compare plans and choose one, and can better understand the benefits and costs they have under the plan in which they are enrolled.

The new, standard summaries will include information on important elements of the coverage, such as the deductible, co-pays, services not covered by the plan, and whether enrollees need a referral to see a specialist – all presented in a way that makes it easier for consumers to make an apples-to-apples comparison of their coverage options. The Summary of Benefits and Coverage (SBC) must also include “coverage examples” of two common medical conditions (managing diabetes and having a baby), offered in a format modeled after the “Nutrition Facts” label consumers use now to make informed decisions about food choices. All health insurance companies and employer plans must also provide consumers with a uniform glossary of terms commonly used in health insurance coverage, such as “deductible,” “non-preferred provider,” and “co-insurance.”

Some additional points to keep in mind:

If an employer offers some benefits under a separate policy, such as prescription drug coverage or mental health services, they can provide multiple forms, which may be confusing. Starting in late 2013, employers will have to combine all information on one form.

The SBC requirement applies to all plans, whether you buy it on your own or get it from an employer.

Health plans must automatically provide the standard summary to a person who completes an application for coverage or to any person who requests a summary (within seven days). Employers must provide the summary when coverage renews (30 days prior to renewal) and upon request (within seven business days). Employers must also provide an updated summary if there is a substantial change in coverage during the plan year.

For a sample of the new SBC, click here.

To see the Uniform Glossary of terms, click here.

Prior Authorizations

Prior Authorization is the process used by insurers to gain additional information, typically from your physician or healthcare provider, before providing coverage of some medications, medical equipment and supplies. Prior authorization differs from precertification, which is often required before inpatient admissions and select hospital procedures and services. In the case of both prior authorization and pre-certification, the insurer may deny coverage if approval is not secured prior to accessing the treatment or service. Please note that definitions of certain terms may vary across insurance companies.

Insurers make individual decisions on when prior authorization and pre-certifications are necessary. It is important to check with your insurer to understand their requirements, including any restrictions on out-of-network providers. Unfortunately, there are situations in which a formal prior authorization procedure is not required, but a plan may still deny coverage of a medication or treatment.

If prior authorization is needed, discuss this with your physician to ensure they are aware of the requirement. Follow up to ensure all of the necessary forms are completed and approved before accessing the service.

Examples of documentation that are often required in order to access immunoglobulin therapy include:

Diagnosis codes Immunological workup such as quantitative serum immunoglobulin levels Measurement of specific antibodies to vaccines, sometimes called vaccine challenge test

results Other pertinent information such as hospitalizations, use of antibiotics, and documented

infections

Once prior authorization is granted, the process may need to be renewed after a defined period of time. This is called a reauthorization. A physician may be required to provide a progress report and updated tests to secure reauthorization. This will vary by plan and the benefit being approved. It is important to keep track of when the authorization expires to maintain continuous coverage.

What if I am Denied Coverage?Appeals and Grievances

Dealing with insurance companies can be a complicated and frustrating endeavor and even more so when dealing with a chronic illness, such as a primary immunodeficiency disease. Should your insurance plan deny coverage of a medically necessary treatment, you could be left in an anxious situation not knowing how you will get your next dosage. Fortunately, there are options available to you that will allow you to appeal your insurance company’s decision. In addition to filing an appeal, you may also wish to speak with an insurance case manager, should your plan provide one, as a resource regarding your grievance.

How to File an Internal AppealWhen you request an internal appeal, your insurance company may ask your provider for more information in order to make a decision about the claim. They should inform you of the deadline to send additional information and if a deadline is not given, call your insurer at the number on the back of your ID card. Remember, you should receive the denial in writing. Be proactive and call your insurance company.

Steps in the Appeal Process

1. You have the right to appeal this decision in writing to the appropriate department. You can find the address to submit appeals in the denial letter, your coverage documents or by contacting your insurer using the member services telephone number on your ID card. Write a clear and simple letter providing:

1. Pertinent clinical information regarding your health history and treatment history; Your medical records documenting past drug trials and health history. Your prescribing physician should have these.

2. History of any adverse reactions or side effects you have had to similar treatments 3. If your insurer requires the prescribing physician to complete a drug authorization form,

you should make sure this has been done; and4. If you received a letter of denial for the treatment, ensure that the information

provided directly addresses the reasons for the denial.5. If the dispute is over the medical necessity of your treatment, your physician’s support in

the form of a letter including studies supporting the benefit of the treatment in question is invaluable. Request that your physician write a letter of medical necessity. A service is medically necessary if it meets any one of the three standards below:

The service or benefit will, or is reasonably expected to, prevent the onset of an illness condition, or disability.

The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition or disability.

The service or benefit will assist the individual to achieve or maintain maximum functional capacity in performing daily activities taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age.

The letter should assert that the prescribed treatment is medically necessary and:

Any product on the formulary would not be as effective and/or would be harmful to you.

All other product or dosage alternatives on the plan’s formulary have been

ineffective or caused harm, or based on sound clinical evidence and knowledge of the patient, are likely to be ineffective or cause harm.

6. Contact your insurer after submitting your request to make sure they have received it.

2. Your physician can request a peer-to-peer review to discuss the specific reason why this type of treatment is needed for you if the initial appeal is unsuccessful.

3. Follow up. If your appeal is denied, go to the next level of appeal. Do not assume this happens automatically – make sure you communicate your desire for a second-level, or Independent External Review. This will be a reconsideration of your original claim by professionals with no connection to your insurance plan. If the independent reviewers think your plan should cover your claim, your health plan must cover it.

Your rights when you are denied coverage: The Affordable Care Act (ACA) includes new rules that spell out how your plan must handle your appeal (usually called an “internal appeal”). If your plan still denies payment after considering your appeal, the ACA permits you to have an independent review organization decide whether to uphold or overturn the plan’s decision. This final check is often referred to as an “external appeal.”

Under the new rules: When your plan denies a claim, it is required to notify you of the reason the claim was

denied, your right to file an internal appeal, your right to request an external review if your internal appeal was unsuccessful, and the availability of a Consumer Assistance Program (CAP) that can help you file an appeal or request a review (if your state has such a program).

When you request an internal appeal, your plan must give you its decision within:o 72 hours after receiving your request when you are appealing the denial of a claim

for urgent care. (If your appeal concerns urgent care, you may be able to have the internal appeal and external review take place at the same time).

o 30 days for denials of non-urgent care you have not yet received.o 60 days for denials of services you have already received.

If after internal appeal the plan still denies your request for payment or services, you can ask for an independent external review. Your plan must include information on your denial notice about how to request this review. If the external reviewer overturns your insurer’s denial, your insurer must give you the payments or services requested in your claim.

How much these new rules will change your current appeal rights depends on the state you live in and the type of plan you have. Some group plans may require more than one level of internal appeal before you are allowed to submit a request for an external review. However, all levels of the internal appeals process must be completed within the timeframes above.

Medicare

Medicare is health and hospitalization insurance for people older than 65 or for those who are disabled. Most portions of Medicare are not free and premiums are deducted from your Social Security benefit checks unless you make other payment arrangements.

There are three levels of Medicare Coverage available.

Medicare Part A - Hospital Insurance Part A Medicare is provided at no charge to anyone disabled or over the age of 65 who

has paid Medicare taxes for at least 10 years. It covers the hospitalization costs, over and above your deductible, for the first 60 days of your hospital stay.

Medicare Part B - Doctor, Outpatient and Clinical Services To obtain Medicare Part B coverage, you must pay an additional premium. This coverage pays for 80% of approved doctor and outpatient services. You will be

responsible for the remaining 20%. Be aware, however, that not all doctors accept Medicare. Current Medicare law creates a special provision which creates a benefit for patients with

primary immunodeficiency disease to be covered for home infusions of immunoglobulin therapy under Medicare Part B. Unfortunately, current law specifically excludes Medicare coverage of the items and services necessary to administer intravenous immunoglobulin (IVIG) in the home, including the services of a nurse to perform the infusion, rendering this benefit hollow. For this reason, the majority of Medicare beneficiaries with primary immunodeficiency diseases are forced to either use subcutaneous immunoglobulin (SCIG) or receive IVIG only in the outpatient hospital, infusion center or physician office settings.

Medigap Supplemental Insurance Medigap is supplemental private insurance that will pay for the 20% of costs not covered by

Medicare Plan B. If you do not sign up for Medigap at age 65, you can enroll later, but you will be subject to underwriting, which may be a problem if you are in poor health or have chronic conditions. Signing up at age 65 is your best option, and you are guaranteed to get the insurance at the lowest cost, and no one can take it away.

If you are a person with Medicare under 65 and have a disability, you might not be able to buy the Medigap policy you want, or any Medigap policy, until you turn 65. Federal law does not require insurance companies to sell Medigap policies to people under 65. However, some states require Medigap insurance companies to sell you a Medigap policy, even if you are under 65. At the time of the printing of the “2012 Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare,” the following states required insurance companies to offer at least one kind of Medigap policy to people with Medicare for people under 65:

California; Colorado; Connecticut; Delaware; Florida; Georgia; Hawaii; Illinois; Kansas; Louisiana; Maine; Maryland; Massachusetts; Michigan; Minnesota; Mississippi; Missouri; New Hampshire; New Jersey; New York; North Carolina; Oklahoma; Oregon; Pennsylvania; South Dakota; Tennessee; Texas; Vermont; and Wisconsin.

Medicare Part C – Medicare Advantage Plan A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice you

may have as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare.

If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D), however not all do.

Prior to enrollment, you can call the Medicare Advantage Plan you are considering to verify if

they provide prescription drug coverage (Part D) in their plan. Like with private insurance, it is important to check on individual Medicare Advantage Plans to

ensure that they will cover immunoglobulin (Ig) replacement therapy treatment.

Medicare Part D – Prescription Drug Coverage Medicare offers prescription drug coverage to all beneficiaries. If you decide not to join a

Medicare drug plan when you are first eligible, and you do not have other creditable prescription drug coverage, you will likely pay a late enrollment penalty.

To get Medicare prescription drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered.

In 2012, Part D enrollees will continue receiving a 50% discount on the total cost of their brand-name drugs while in the “donut hole” or coverage gap. The full retail cost of the drugs will still apply to getting out of the donut hole even though 50% was paid for by the pharmaceutical manufacturers. Enrollees will pay a maximum of 86% co-pay on generic drugs while in the coverage gap.

For more information on the levels of Medicare visit www.medicare.gov or call 800.633.4227.

Those who are already receiving Social Security benefits will automatically be enrolled in Medicare Parts A and B. However, because there is a premium for Part B coverage, you have the option of turning it down. You will be contacted by mail a few months before you become eligible and given all the information you need. (Note: Residents of Puerto Rico or foreign countries will not receive Part B automatically. They must elect this benefit.)

Even if you keep working after you turn 65, you should sign up for Medicare Part A. If you have health coverage through your employer or union, Part A may still help pay some of the costs not covered by your group health plan. Call the Social Security Administration at 800.772.1213 to sign up. However, you may want to wait to sign up for Medicare Part B if you or your spouse are working and have group health coverage through you or your spouse's employer or union. You would have to pay the monthly Medicare Part B premium, and the Medicare Part B benefits may be of limited value to you as long as the group health plan is the primary payer of your medical bills.

However, if you or your spouse (or family member if you are disabled) is still working and you have insurance through that employer (including the Federal Employee Health Benefits Program) or union, contact your employer or union benefits administrator to find out how your insurance works with Medicare. It may be to your advantage to delay Part B enrollment.

You can sign up for Part B any time you have current employer insurance. (COBRA and retiree insurance do not count as current employer insurance.)

Once your employment ends, three things happen:

1. You have eight months to sign up for Part B without a penalty. This period will run whether or not you choose COBRA. If you choose COBRA, don't wait until your COBRA ends to enroll in Part B. If you don't enroll in Part B during the eight months, you may have to pay a penalty; you won't be able to enroll until the next General Enrollment Period; and you'll have to wait before your coverage begins. (You may elect Part B coverage during the General Enrollment Period, which extends from January 1 through March 31 each year. Enrollment becomes effective on July 1 of the same year however you will not be able to elect a Part D plan until

Open Enrollment which extends from October 15 through December 7 each year.)

2. You may be able to get COBRA coverage, which continues your health insurance through the employer's plan (in most cases for only 18 months) and probably at a higher cost to you.

3. If you already have COBRA coverage when you enroll in Medicare, your COBRA will probably end. If you become eligible for COBRA coverage after you are already enrolled in Medicare, you must be allowed to take the COBRA coverage. It will always be secondary to Medicare (unless you have End Stage Renal Disease).

TRICARE is insurance for active duty military or retirees and their families. When you have Medicare Part A, you must have Medicare Part B to keep your TRICARE coverage.

In certain cases, you can delay your Medicare Part B enrollment without having to pay higher premiums. If you didn’t take Medicare Part B when you were first eligible because you or your spouse were working and had group health plan coverage through you or your spouse’s employer or union, you can sign up for Medicare Part B during a Special Enrollment Period (SEP). You can sign up:

Anytime you are still covered by the employer or union group health plan through your or your spouse’s current or active employment, or

During the eight months following the month the employer or union group health plan coverage ends or when the employment ends (whichever is first).

Please be aware that if you decide to pick up Part B coverage at a later date, the cost of Part B may go up 10% for each 12-month period that you could have had Part B but did not sign up for it, unless you have insurance from your or your spouse's current job. Also, if you decline or cancel your Part B coverage, you will not be eligible to receive Medicare covered preventive services.

In most cases you will have to pay that penalty every month for as long as you have Medicare. If you are enrolled in Medicare because of a disability and pay premium penalties, once you turn 65, you no longer have to pay the premium penalty.

When you are covered by more than one insurance plan and any of the following situations apply to you, your other insurance may be primary to Medicare, meaning the other insurance pays first:

You have Medicare; are still working; and are covered by your employer’s health insurance plan; you have Medicare, are retired or disabled, but your spouse is working and has a health plan that also covers you; or you are injured on the job, in an automobile accident, or slip and fall at a shopping center (worker’s compensation, auto insurance or liability insurance may cover the cost of medical care related to the accident).

Medicare has a dedicated “Coordination of Benefits Contractor” that keeps track of when Medicare is primary or when another insurer is primary. You can contact the Coordination of Benefits Contractor at 800.999.1118 for questions about, or to report changes in, your primary insurance. If you have other insurance and it pays after Medicare, it is called your supplemental insurance.

The Medicare publication, Medicare and Other Health Benefits: Your Guide to Who Pays First (http://www.medicare.gov/Publications/Pubs/pdf/02179.pdf) contains additional information on this topic that you may find useful.

Acronyms and GlossaryHealthcare and Insurance Related Acronyms

Glossary of Healthcare Terms

ACA: Affordable Care ActACO: Accountable Care OrganizationCAP: Consumer Assistance ProgramCHIP: Children’s Health Insurance ProgramCOB: Coordination of BenefitsCOBRA: Consolidated Omnibus Budget Reconciliation ActDME: Durable Medical EquipmentEOB: Explanation of BenefitsEPO: Exclusive Provider OrganizationFMLA: Family and Medical Leave ActFPL: Federal Poverty LevelFSA: Flexible Spending AccountGEP: General Enrollment PeriodHDHP: High Deductible Health PlanHHS: Health and Human ServicesHIPAA: Health Insurance Portability and Accountability ActHMO: Health Maintenance OrganizationHRA: Health Reimbursement ArrangementHSA: Health Savings AccountMAP: Medicare Advantage PlanMLR: Medical Loss RatioOEP: Open Enrollment PeriodOON: Out-Of-NetworkOOP: Out-Of-PocketPBM: Pharmacy Benefit ManagerPCIP: Pre-existing Condition Insurance PlanPCP: Primary Care PhysicianPDP: Prescription Drug PlanPFTs: Pulmonary Function TestsPOS: Point-of-Service PlanPPO: Preferred Provider OrganizationSEP: Special Enrollment PeriodSNF: Skilled Nursing FacilityTPA: Third Party AdministratorUCR: Usual, Customary and Reasonable

Healthcare Plans and Systems

Catastrophic Plan: A healthcare plan that only covers certain types of expensive care, like hospitalizations. It may also include plans that have a high deductible, so that your plan begins to pay only after you have first paid up to a certain amount for covered services.

Children’s Health Insurance Program (CHIP): Insurance program jointly funded by state and federal government that provides health insurance to low-income children and, in some states, pregnant women in families who earn too much income to qualify for Medicaid but cannot afford to purchase private health insurance coverage.

Durable Medical Equipment (DME): Specialized equipment that is prescribed by a healthcare provider and furnished by a supplier, which is to be used in a patient's home or institutions constituting a home. DME may include but are not limited to items such as standard oxygen delivery systems, hospital bed, wheelchair, walker, traction apparatus, intermittent positive pressure breathing machine, brace, crutch or any other items that are determined Medically Necessary.

EPO (Exclusive Provider Organization) Plan: A managed care plan in which services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).

Flexible Spending Account (FSA): Accounts offered and administered by employers that allow employees to set aside, out of their paycheck, pretax dollars to pay for the employee’s share of insurance premiums or medical expenses not covered by the employer’s health plan. The employer may also make contributions to a FSA. Typically, benefits or cash must be used within the given benefit year or the employee loses the money. Flexible spending accounts can also be provided to cover childcare expenses, but those accounts must be established separately from medical FSAs.

HMO (Health Maintenance Organization): An insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. Generally the plan will not cover out-of-network care except in an emergency, and may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

Health Reimbursement Arrangement (HRA): A medical savings account to which employers contribute funds that can cover an employee’s costs not covered by the plan. The employer can choose whether or not to allow unused funds to rollover to the following year.

Health Savings Account (HSA): A medical savings account available to taxpayers who are enrolled in a High Deductible Health Plan (HDHP) that meets federal rules. In 2012, to qualify for use with an HSA, an HDHP plan must have a minimum deductible of $1,200 for an individual plan and $2,400 for a family plan, and an out-of-pocket maximum of $6,050 for an individual plan and $12,100 for a family plan (these number are adjusted annually). The funds contributed to the account are not subject to federal income tax at the time of deposit. Funds must be used to pay for qualified medical expenses. Unlike a Flexible Spending Account (FSA), funds roll over year to year if you do not spend them.

High Deductible Health Plan (HDHP): A plan that features higher deductibles than traditional insurance plans. HDHPs can be combined with a health savings account (under certain circumstances) or a health reimbursement arrangement to allow you to pay for qualified out-of- pocket medical expenses on a pre-tax basis. See Health Savings Account (HSA).

High Risk Pool Plan (State): Safety net plan that provides coverage if you have been locked out of the individual insurance market because of a pre-existing condition. May also offer coverage if you are HIPAA eligible or meet other requirements. High-risk pool plans offer health insurance coverage that is subsidized by a state government. Typically, your premium is up to twice as much as you would pay for

individual coverage if you were healthy. Not all states offer high risk pools, and those that do have distinct rules in terms of cost, eligibility and benefits.

Managed care plan: A plan that generally provides comprehensive health services to its’ members, and offers financial incentives for patients to use the providers who belong to the plan. Examples include: health maintenance organizations (HMOs), preferred provider organizations (PPOs), exclusive provider organizations (EPOs), and point of service plans (POSs).

Medicaid: A state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities, and in some states, other adults. The federal government provides a portion of the funding and sets guidelines. States also have choices in how they design their program, so Medicaid programs and eligibility vary state by state and may have a different name in your state.

Medicare: A federal health insurance program for people who are age 65 or older and certain younger people with disabilities. It also covers people with End-Stage Renal Disease.

Medicare Part A: Hospital insurance that helps cover inpatient care in hospitals, skilled nursing facility, hospice and home care.

Medicare Part B: Medical coverage that helps to cover medically-necessary services like doctors' services, outpatient care, home health services, other medical services and preventive services.

Medicare Advantage (Medicare Part C): A type of Medicare health plan offered by a private company that contract with Medicare to provide Medicare Part A and Part B benefits.

Medicare Part D: A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage.

POS (Point-of-Service Plan) Plan: A type of plan in which you pay less if you use doctors, hospitals, and other healthcare providers that belong to the plan’s network. POS plans may also require you to get a referral from your primary care doctor in order to see a specialist.

PPO (Preferred Provider Organization): A type of healthcare plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals and providers outside of the network for an additional cost.

Pre-existing Condition Insurance Plan (PCIP): A new program that will provide a health coverage option if you have been uninsured for at least six months, have a pre-existing condition, and have been denied coverage (or offered insurance without coverage of the pre-existing condition) by a private insurance company. Provides coverage until 2014 when you will have access to affordable health insurance choices through an Exchange, and you can no longer be discriminated against based on a pre-existing condition. Every state has a PCIP program; in some states it is operated by the state while in others it is operated by the federal government.

Pharmacy Benefit Manager (PBM): A third party administrator of prescription drug programs. They are primarily responsible for processing and paying prescription drug claims. They also are responsible for developing and maintaining the formulary, contracting with pharmacies, and negotiating discounts and rebates with drug manufacturers.

PCP (Primary Care Physician): A physician who usually is the first health professional to examine a patient and who recommends secondary care physicians, medical or surgical specialists with expertise in the patient's specific health problem, if further treatment is needed. Formerly known as the family doctor.

Health Insurance and Reform

Accountable Care Organization (ACO): A group of healthcare providers who give coordinated care, chronic disease management, and thereby improve the quality of patient care. The organization’s payment is tied to achieving healthcare quality goals and outcomes that result in cost savings. ACOs can include various types of doctors – primary care, specialists, etc. – as well as other medical providers (nurses, physician’s assistants, etc.) and institutions (hospitals, multi-physician practices).

Affordable Care Act (ACA): The comprehensive healthcare reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Healthcare and Education Reconciliation Act on March 30, 2010. Affordable Care Act refers to the final, amended version of the law.

Allowed Charge: Discounted fees that insurers will recognize and pay for covered services. Insurers negotiate these discounts with providers in their health plan network, and network providers agree to accept the allowed charge as payment in full. Each insurer has its own schedule of allowed charges.

Annual Limit: A cap on the benefits your insurance company will pay in a year while you are enrolled in a health insurance plan. Annual caps are sometimes placed on particular services such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered services or on the number of visits for a particular service. After the annual limit is reached, you must pay all associated healthcare costs for the rest of the year. Under the Affordable Care Act, all group health plans (existing and new) and all new individual policies (issued after 3/23/2010) must phase out annual limits. Plan or policy years starting after 9/23/2011 but before 9/23/2012 cannot have an annual limit lower than $1.25 million. For the following year, plans cannot have an annual limit lower than $2 million. No annual dollar limits are allowed on “essential” services in 2014.

Balance Billing: The practice of billing a patient for charges not paid by his/her insurance plan because the charges are in excess of covered amounts. Balance billing amounts will often be charges that are above the usual and customary rates.

Benefits: The healthcare items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.

Biosimilar Biological Products: The generic version of more complicated medications. Technically, they are reproductions of biotechnologically manufactured biopharmaceuticals that partially mimic proteins naturally present in the body.

Care Coordination: The process of organizing your treatment across several healthcare providers. Medical homes and accountable care organizations (see definition) are two common ways to coordinate care.

Chronic Disease Management: An integrated care approach to managing illness – typically using multiple healthcare providers including various physicians, nurses, and others – which includes screenings, check-ups, monitoring and coordinating treatment, and patient education. It can improve quality of life while reducing healthcare costs if you have a chronic disease, by preventing or minimizing the effects of a disease.

Claim: A request for payment that you or your healthcare provider submits to your health insurer when you get items or services you think are covered.

COBRA: (Consolidated Omnibus Budget Reconciliation Act) A federal law that may allow you to temporarily keep health coverage if your employment ends, you lose coverage as a dependent of the covered employee, or if there is another qualifying event. COBRA requires you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.

Co-insurance: A form of medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage of medical expenses after the deductible amount, if any, was paid. Once any deductible amount and coinsurance are paid, the insurer is responsible for the rest of the reimbursement for covered benefits up to allowed charges: the individual could also be responsible for any charges in excess of what the insurer determines to be ‘usual, customary and reasonable.’

Co-payment: A flat dollar amount you must pay for a covered program. Example: you may have to pay a $15 copayment for each covered visit to a primary care doctor.

Cost Sharing: The share of costs covered by your insurance that you pay out-of-pocket. Generally includes deductibles, coinsurance and copayments, or similar charges, but it does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.

Creditable Coverage: Health insurance coverage under any of the following: a group health plan; individual health insurance; student health insurance; Medicare; Medicaid; CHAMPUS and TRICARE; Veterans Administration (VA) coverage; the Federal Employees Health Benefits Program; Indian Health Service; the Peace Corps; Public Health Plan (any plan established or maintained by a State, the U.S. government, a foreign country), including the new federal high risk pool (PCIP, or the Pre-Existing Condition Insurance Program); Children’s Health Insurance Program (CHIP) or a state health insurance high risk pool. If you have prior creditable coverage, it will reduce the length of a pre-existing condition exclusion period under new job-based coverage.

Depending on state law, this may also apply to other types of coverage, such as state high risk pools, in your state.

Deductible: The amount you must pay for covered care before your health insurance begins to pay. Insurers apply and structure deductibles differently. Example: under one plan, a comprehensive deductible might apply to all services while another plan might have separate deductibles for benefits such as prescription drug coverage. Some plans may also cover some services before the deductible is met, such annual exams.

Dependent Coverage: Insurance coverage for family members of the policyholder, such as spouses, children, or partners. Under the Affordable Care Act, plans must cover children up to age 26 on their parent’s policy.

Disability: A limit in a range of major life activities. This includes activities like seeing, hearing, walking and tasks like thinking and working. Different state, federal or private programs may have different disability standards. A legal definition of disability can be found at: www.ada.gov/pubs/ada.htm

Donut Hole, Medicare Prescription Drug: Most plans with Medicare prescription drug coverage (Part D) have a coverage gap, called a donut hole. This means that after you and your drug plan have spent a certain amount of money for covered drugs you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.

Emergency Room Services: Evaluation and treatment of an illness, injury or condition that needs immediate medical attention in an emergency room.

Essential Health Benefits: A set of healthcare service categories that must be covered by certain plans, starting in 2014. The Affordable Care Act defines essential health benefits to “include at least the following general categories and the items and services covered within the categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.’’

All new plans sold to individuals and small businesses, including those offered in Exchanges, and all Medicaid state plans must cover these services by 2014.

Starting with plan years or policy years that began on or after September 23, 2010, health plans can no longer impose a lifetime dollar limit on spending for these services. All plans, except grandfathered individual health insurance policies, must begin phasing out annual dollar spending limits for these services starting with plan/policy years that began on or after September 23, 2010. For the majority of health insurance plans, annual dollar limits on essential health benefits will be completely phased out by 2014.

The Department of Health and Human Services has issued guidance outlining a process for selecting EHBs in each state, based on existing coverage options in the small group and other employer plans. States are expected to make these choices in the Fall of 2012. Learn more about this process at www.healthcare.gov .

Exchange: New state-based organizations that will be set up to create a more organized and competitive market place for individuals and small businesses to buy health insurance. Exchanges will offer a choice of different health plans, which meet certain benefits and cost standards and provide information to help consumers better understand their options.

Exclusions: Items or services that are not covered under a contract for insurance and which an insurance company won’t pay. Example: your policy may not cover pregnancy care or any services related to a pre-existing condition.

Explanation of Benefits (EOB): A form or document sent by the insurance company to both enrollees and providers. The document provides necessary information about claim payments and patient responsibility amounts of healthcare services however it is not a bill. It should include data on

what was paid or is in process of being reviewed for payment by the insurance company. Your EOBs may help you track your healthcare expenditures and serve as a reminder of the medical services you received during the past several years.

Family and Medical Leave Act (FMLA): A federal law that guarantees up to 12 weeks of job protected leave for certain employees when they need to take time off due to serious illness or disability, to have or adopt a child or to care for another family member. When on leave under FMLA, you can continue coverage under your job-based plan. Learn more about FMLA at: http://www.dol.gov/whd/fmla.

Federal Poverty Level (FPL): A measure of income level issued annually by the Department of Health and Human Services. FPL is used to determine eligibility for certain programs and benefits. For more information on FPL please visit: http://aspe.hhs.gov/poverty/12poverty.

Fee for Service: A reimbursement plan in which doctors and other healthcare providers are paid for each service performed, such as for tests and office visits.

Flexible Benefits Plan: Offers employees a choice between various benefits including cash, life insurance, health insurance, vacations, retirement plans, and child care. Although a common core of benefits may be required, you can choose how your remaining benefit dollars are to be allocated for each type of benefit from the total amount promised by the employer. Sometimes you can contribute more for additional coverage. Also known as a Cafeteria plan or IRS 125 Plan.

Formulary: A list of drugs your insurance plan covers. May include how much you pay for each drug. If the plan categorizes drugs into different groups requiring different co-pays – also known as tiers – then the formulary may list drugs by these tiers. Formularies may include both generic drugs and brand-name drugs.

Fully Insured Job-based Plan: A plan in which the employer contracts with an insurer to assume financial responsibility for the enrollees’ medical claims and for all incurred administrative costs.

General Enrollment Period: Medicare beneficiaries who did not enroll in Part B when they first became eligible for Medicare may elect Part B coverage during the General Enrollment Period, which extends from January 1 through March 31 each year. Enrollment becomes effective on July 1 of the same year.

Grandfathered Health Plan: As defined in the Affordable Care Act, a group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. Grandfathered plans are exempt from many changes required under the Affordable Care Act. Plans or policies may lose their grandfathered status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions. Also see “New Plan” below.

Guaranteed Issue: A requirement that health plans must permit you to enroll regardless of health status, age, gender or other factors that might predict the use of health services. Except in some states, guaranteed issue does not limit how much you can be charged if you enroll.

Guaranteed Renewal: A requirement that your health insurance issuer must offer to renew your

policy as long as you continue to pay premiums. Except in some states, guaranteed renewal does not limit how much you can be charged if you renew your coverage.

Healthcare Workforce Development: The use of incentives and recruiting to encourage people to enter into healthcare professions such as primary care and to encourage providers to practice in underserved areas.

Health Insurance Portability and Accountability Act (HIPAA): A 1996 federal act that eliminated discrimination by health insurers for those with preexisting medical conditions. Example: when leaving a group policy, patients cannot be denied coverage in other group policies based on a pre-existing medical condition. In order to qualify for HIPPA, you must meet the following two conditions: (1) you have had 18 months of consecutive, continuous prior health coverage, and (2) you must get new coverage with another group medical plan within 63 days. Many insurance plans offer open-enrollment periods when anyone can join, regardless of preexisting conditions.

Health Status: Refers to your medical conditions (both physical and mental health), claims experience, receipt of healthcare, medical history, genetic information, evidence of insurability and disability.

HIPAA Eligible Individual: Your status once you have had 18 months of continuous creditable health coverage. To be HIPAA eligible, at least the last day of your creditable coverage must have been under a group health plan: you also must have used up any COBRA or state continuation coverage for which you are eligible; you must not be eligible for Medicare or Medicaid; you must not have other health insurance; and you must apply for individual health insurance within 63 days of losing your prior creditable coverage. When you are buying individual health insurance, HIPAA eligibility gives you greater protections than you would otherwise have under state law.

Home Healthcare: Healthcare services and supplies in your home that a doctor approves under a plan of care established by your doctor.

Individual Health Insurance Policy: Policies for people who are not connected to job-based coverage. Individual health insurance policies are regulated under state law. Note that the phrase “individual policies” when used in this way – policies that are unconnected to employment – can be used for policies that cover a single person or multiple people (families, mother and dependent child, husband and wife, etc.).

Individual Responsibility: Under the Affordable Care Act, starting in 2014, you must be enrolled in a health insurance plan that meets basic minimum standards. If you aren’t, you may be required to pay a penalty. Exempt from this are people with very low income for whom coverage is unaffordable based in their household income, or for other reasons, including religious beliefs.

In Network Provider: A physician, certified nurse midwife, hospital, skilled nursing facility, home healthcare agency, or any other duly licensed or certified institution or health professional under contract with your insurance provider.

Insurance Co-Op: A non-profit entity in which the same people who own the company are insured by the company. Cooperatives can be formed at a national, state or local level, and can include doctors, hospitals and businesses as member-owners.

Job-based Health Plan: Coverage that is offered to an employee (and often his or her family) by

an employer.

Lifetime Limit: A cap on the total lifetime benefits you may get from your insurance policy. An insurance company may impose a total lifetime dollar limit on benefits (like $1 million) or limit specific benefits (like a $200,000 lifetime cap on organ transplants or one gastric bypass per lifetime) or a combination of the two. After a lifetime limit is reached, the insurance plan will no longer pay for covered services. By September 23, 2011, the majority of policies should not have lifetime dollar limits on essential health benefits.

Long-Term Care: Medical and non-medical services provided to people who are unable to perform basic activities of daily living such as dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living or in nursing homes. Individuals may need long-term supports and services at any age. Medicare and most health insurance plans do not pay for long-term care.

Managed care provisions: Features within health plans that provide insurers with a way to manage the cost, use and quality of healthcare services received by group members. Examples of managed care provisions include:

Preadmission certification - Authorization for hospital admission given by a healthcare provider to a group member prior to hospitalization. Failure to obtain a preadmission certification in non-emergency situations reduces or eliminates the healthcare provider’s obligation to pay for services rendered.

Utilization review - The process of reviewing the appropriateness and quality of care provided to patients. Utilization review may take place before, during, or after the services are rendered.

Preadmission testing - Requirement designed to encourage patients to obtain necessary diagnostic services on an outpatient basis prior to non-emergency hospital admission. The testing is designed to reduce the length of a hospital stay.

Non-emergency weekend admission restriction - A requirement that imposes limits on reimbursement to patients for non-emergency weekend hospital admissions.

Second surgical opinion - A cost-management strategy that encourages or requires patients to obtain the opinion of another doctor after a physician has recommended that a non- emergency or elective surgery be performed. Programs may be voluntary or mandatory in that reimbursement is reduced or denied if the participant does not obtain the second opinion. Plans usually require that such opinions be obtained from board-certified specialists with no personal or financial interest in the outcome.

Medical Loss Ratio (MLR): A financial measurement used in the Affordable Care Act to encourage health plans to provide value to enrollees. Example: If an insurer uses 80 cents of every premium dollar to pay its customers’ medical claims and activities that improve the quality of care, the company has a medical loss ratio of 80%. This indicates that the insurer is using the remaining 20 cents of each premium dollar to pay overhead expenses, including salaries, administrative costs, and agent commissions. The Affordable Care Act sets minimum medical loss ratios for different markets, as do some state laws. Insurers who do not meet the minimum MLR must issue rebates to policy holders beginning in 2012.

Medically Necessary: Services or supplies that are needed for the diagnosis or treatment of your health condition and meet accepted standards of medical practice. Definitions of medical necessity vary by plan.

Medical Underwriting: A process used by insurance companies that uses your health status when you are applying for health insurance coverage to determine whether to offer you coverage, at what price and with what exclusions or limits.

Minimum Essential Coverage: The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act. This includes individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage.

New Plan: As referenced in the Affordable Care Act, a health plan that is not grandfathered and therefore subject to all of the reforms in the Affordable Care Act. In the individual health insurance market, a plan that your family is purchasing for the first time. In the group health insurance market, a plan that your employer is offering for the first time. New employees and new family members may be added to existing grandfathered group plans – so a plan that is new to you and your family may still be a grandfathered plan.

In both the individual and group markets, a plan that loses its grandfathered status will be considered a new plan. This happens when it makes significant changes to the plan, such as reducing benefits or increasing cost-sharing for enrollees. Also see “Grandfathered Plan” above.

Nondiscrimination: A requirement that job-based insurance not discriminate based on health status by denying or restricting health coverage, or charging more. Job-based plans can restrict coverage based on other factors such as part-time employment that are not related to health status.

Open Enrollment Period (OEP): The period of time set up to allow you to choose from available plans, usually once a year.

Out-of-Network (OON) Providers: A duly licensed or certified institution or health professional not under contract with your insurance provider.

Out-of-Pocket Costs: Your expenses for medical care that are not reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance and copayments for covered services plus all costs for services that are not covered.

Out-of-Pocket Limit (OOP): The maximum amount you will be required to pay for covered services in a year. Generally, this includes the deductible, coinsurance, and copayments (varies from plan to plan). Example: In some plans the out-of-pocket limit does not include cost sharing for all services, such as prescription drugs. Plans may have different out-of-pocket limits for different services. In Medicaid and CHIP, the limit includes premiums. Additionally, many plans do not have out-of-pocket limits.

Plan Year: A 12-month period of benefits coverage under a group health plan. This 12-month period might be different than the calendar year.

Policy Year: A 12-month period of benefits coverage under an individual health insurance plan. This 12-month period might be different than the calendar year.

Pre-authorization: A pre-authorization requirement means that the insurance company will not pay for a service unless the provider gets permission to provide the service. This permission is to ensure that a patient has benefit dollars remaining and that a particular kind of service is eligible for payment

under the patient's contract. Authorization could be granted retroactively after receiving emergency care; generally a patient or hospital may have a 24-hour window to notify a payer.

Pre-certification: A pre-certification requirement means that a payer must review the medical necessity of a proposed service and provide a certification number before a claim will be paid. This is often true with augmentation therapy as well as other elective procedures. A physician or nurse with the payer must review a physician's order and the medical record to agree that a proposed procedure is medically appropriate. (Many insurers have adopted strict guidelines in regards to coverage for augmentation therapy.)

Pre-existing Condition (Job-based Coverage): Any condition (either physical or mental) including a disability for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on your enrollment date in a health insurance plan. Genetic information, without a diagnosis of a disease or a condition, cannot be treated as a pre- existing condition. Pregnancy cannot be considered a pre-existing condition and newborns, newly adopted children and children placed for adoption who are enrolled within 30 days cannot be subject to pre-existing condition exclusions. This term is defined under state law and varies significantly by state.

Pre-existing Condition Exclusion Period (Job-based Coverage)*: The time period during which a health plan won’t pay for care relating to a pre-existing condition. This cannot exceed 12 months for a regular enrollee or 18 months for a late-enrollee.

Pre-existing Condition Exclusion Period (Individual Policy)*: The time period during which an individual policy will not pay for care relating to a pre-existing condition. Conditions may be excluded permanently (known as an exclusionary rider). Rules on pre-existing condition exclusion periods in individual policies vary widely by state.

*Pre-existing conditions exclusions for children under age 19 are prohibited for plan years effective after September 23, 2010 and will be prohibited for adults for plan years effective after January 1, 2014.

Premium: A monthly payment you make to your insurer to get and keep insurance coverage. Premiums can be paid by employers, unions, employees or individuals or shared among different payers.

Preventive Services: Routine healthcare that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

Primary Care: Health services that cover a range of prevention, wellness and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health-related issues. They may also coordinate your care with specialists.

Qualified Health Plan: Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by an Exchange, provides essential health benefits, follows established limits on cost- sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Exchange in which it is sold.

Qualifying Event: Any event or occurrence such as death, termination of employment, divorce or a terminal illness that changes an employee's eligibility status and permits an acceleration or

continuation of benefits or coverage under a group health plan. The term is most frequently used in reference to COBRA eligibility

Rate Review: A process that allows state insurance departments to review rate increases before insurance companies can apply them to you. Under the Affordable Care Act, insurers that submit rate increases of 10% or more are considered “unreasonable” and are subject to additional review.

Reinsurance: A reimbursement system that protects insurers from very high claims. It usually involves a third party paying part of an insurance company’s claims once they pass a certain amount. Reinsurance is a way to stabilize an insurance market and make coverage more available and affordable.

Rescission: The retroactive cancellation of a health insurance policy. Insurance companies will sometimes retroactively cancel your entire policy if you made a mistake on your initial application when you buy an individual market insurance policy. Under the Affordable Care Act, rescission is illegal except in cases of fraud or intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage.

Rider (exclusionary rider): An amendment to an insurance policy. Some riders add coverage while other riders exclude coverage (known as exclusionary rider). Example: You buy a maternity rider to add coverage for pregnancy to your policy. An exclusionary rider is an amendment permitted in individual policies that permanently excludes coverage for a health condition, body part or body system (such as a certain disease state or disability). Beginning in September 2010, exclusionary riders cannot be applied to coverage for children. Starting in 2014, no exclusionary riders will be permitted in any health insurance.

Risk Adjustment: A statistical process that takes into account the underlying health status and health spending of the enrollees in an insurance plan when looking at their healthcare outcomes or healthcare costs.

Self-Insured Plan: Type of plan usually present in larger companies where the employer itself collects premiums from enrollees and takes on the responsibility of paying employees’ and dependents’ medical claims. These employers can contract for insurance services such as enrollment, claims processing, and provider networks with a third party administrator, or they can be self- administered.

Skilled Nursing Facility (SNF) Care: Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Example: Physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

Special Enrollment Period: A time outside of the open enrollment period during which you and your family have a right to sign up for job-based health coverage. Job-based plans must provide a special enrollment period of 30 days following certain life events that involve a change in family status (such as marriage or birth of a child) or loss of other job-based health coverage.

Special Healthcare Need: The healthcare and related needs of children who have chronic physical, developmental, behavioral or emotional conditions. Such needs are of a type or amount beyond that required by children generally.

State Continuation Coverage (“Mini-COBRA”): A state-based requirement similar to COBRA that applies to group health insurance policies of employers with fewer than 20 employees. In some

states, state continuation coverage rules also apply to larger group insurance policies and add to COBRA protections. Example: in some states, older workers (generally 55 or older) leaving a job-based plan may be allowed to continue COBRA coverage until they reach the age of Medicare eligibility.

Third Party Administrator (TPA): An individual or firm hired by an employer to handle claims processing, pay providers, and manage other functions related to the operation of health insurance. The TPA is not the policyholder or the insurer. The TPA may often be a company you associate with health insurance, such as Aetna or Blue Cross, but in this role they are not the actual insurer but are simply managing the plan on behalf of the employer.

Uncompensated Care: Healthcare or services provided by hospitals or healthcare providers that do not get reimbursed. Often uncompensated care arises when people do not have insurance and cannot afford to pay the cost of care.

Usual, Customary, and Reasonable (UCR) Charges: A healthcare provider’s usual fee for a service that does not exceed the customary fee in that geographic area and is reasonable based on the circumstances. Instead of UCR charges, PPO plans often operate based on a negotiated (fixed) schedule of fees that recognize charges for covered services up to a negotiated fixed dollar amount. Conventional indemnity plans typically operate based on UCR charges.

Waiting Period (Job-based coverage): The time that must pass before coverage can become effective for an employee or dependent, who is otherwise eligible for coverage under a job-based health plan. It applies to all new employees and is not based on health status. This is different than a pre-existing condition exclusion period, which is applied to individual employees and is based on health status.

Well-baby/Well-child Visits: Routine doctor visits for comprehensive preventive health services that occur when a baby is young and annual visits until a child reaches age 21. Services include physical exam and measurements, vision and hearing screening and oral health risk assessments.

Wellness Programs: A program intended to improve and promote health and fitness that’s usually offered through the work place, although insurance plans can offer them directly to their enrollees. The program allows your employer or plan to offer you premium discounts, cash rewards, gym memberships, and other incentives to participate. Programs that tie financial incentives to achieving certain outcomes (ie, set goals such as BMI, glucose levels or blood pressure) must meet certain federal rules. Examples of some wellness programs: programs to help you stop smoking, diabetes management programs, weight loss programs, and preventative health screenings.

Source: www.healthcare.gov/glossary/04262011a.pdfThe BLS National Compensation Surve