Foresight family physicians9/5/2023 Certain Qualifying Events trigger COBRA Continuation and they include termination of employment, retirement, death of a spouse, divorce or the reaching of the maximum age of eligibility. Applicable to all groups of 20 or more employees, COBRA affords employees and/or their dependents the opportunity to continue insurance for periods of time ranging from 18 to 36 months. Q: What is COBRA and how does it work?Ī: COBRA which stands for Consolidated Omnibus Budget Reconciliation Act is federally mandated. Generally speaking, after the co-pay has been satisfied, the balance of the expense is picked up by the insurance or other health care carrier. For example, there may be a $5 co-pay for prescriptions or a $10 co-pay for office visits. In the case of the aforementioned $5,000 the insurance company would pay $4,000 (80% of $5,000 ) and the insured could pay $1,000 ( 20% of $5,000 ).Ĭo-payment, on the other hand, refers to the small up front charge paid by the insured before benefits are accessed. If the coinsurance is 80/20%, the company agrees to pay 80% and the insured agrees to pay 20%. For example, after the calendar year deductible has been paid under a major medical plan, the company and the insured share payment of a specific dollar amount of expenses, say $5,000. charges for custodial care Q: What is the difference between coinsurance and co-payment?Ī: Coinsurance refers to cost share. charges for services and supplies that are not deemed medically necessaryĤ8370. charges which exceed reasonable and customary levelsĤ8369. charges for services that are considered experimental or investigationalĤ8368. charges which would not be made in the absence of insuranceĤ8367. Q: What types of expenditures are commonly excluded under major medical plans?Ī: Under traditional major medical plans the following are a few of the typical exclusions:Ĥ8366. Individual health insurance carriers are not constrained by mandates and many limit coverage for mental illness and or substance abuse to a specific lifetime maximum of $10,000 or similar amount. Coverage may be more liberal than state mandated levels. Substance abuse must be covered subject to a member co-payment of no more than $200 per admission for inpatient services for at least 45 days per calendar year. Expenses incurred in connection with behavioral health problems which are biologically based are not subject to the sixty day calendar year limitation. On an out patient basis mental illness must be covered at a level of 50% of the maximum allowable amount up to $2,000 per person per calendar year. ![]() On an inpatient basis mental illness must be treated the same as any other illness for 60 days per member per calendar year. ![]() In Connecticut, coverage for groups of 1 to 50 lives is mandated for mental illness and substance abuse. Q: Is medical expense coverage available for substance abuse and mental illness?Ī: Yes. They are in effect plans with complete freedom of choice of doctors, hospitals and other providers. On the other hand, Traditional Insurance plans do not presuppose limited provider networks. Those that require the use of a PCP are known as closed” or “gatekeepered” plans while those that allow direct access to specialists are known as “open access” plans. These plans may or may not require referrals from a primary care physician. Q: How does Managed Care differ from Traditional Insurance?Ī: Managed Care plans (HMO’s, PPO’s and POS) presuppose the use of a network of hospitals, physicians and other providers. A POS plan is like a PPO in that it offers better ” in-network” than “out-of-network” coverage but it differs from a PPO plan in that a gatekeeper or primary care physician (PCP) is an integral part of the referral process. Generally speaking, PPO’s offer better “in-network” than ” “out-of-network” coverage and do not usually utilize a primary care physician referral process. ![]() Other forms of Managed Care include PPO’s ( Preferred Provider Organizations ) and POS ( Point of Service ) plans. Q: What is the difference between an HMO and Managed Care?Ī: Health Maintenance Organization ( HMO ) is a form of Managed Care.
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