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Frequently Asked Questions About Health Insurance

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Q.   Can’t I just buy “individual” health insurance when I need to have an expensive procedure? 

A.   No.  If you need to receive costly medical care within the first 12 months of purchasing a health insurance policy, insurance companies do not have to provide coverage for pre-existing medical conditions
(anything you’ve been diagnosed with or treated for in the previous 10 years) for up to one year from the start of the policy. Depending on the severity of your illness or procedure the insurance company also
can decline or post pone you for health insurance until the procedure has been completed. Some of the better health insurance policies actually cover controlled pre-existing conditions such as Hyperlipidimia or
Hypertension from day one. But most other pre-existing conditions will not be covered. In order to avoid such a waiting period, once you get health insurance you should always maintain it.

Q.   I’m very healthy so why should I pay expensive monthly health insurance premiums when I “probably” won’t ever go to the doctor? 

A.   Although there may be a “probability,” based on your past health history, that you are not likely to see a doctor, incur a serious injury or develop a life-threatening illness, the fact remains, that you can never
be certain.  If you don’t obtain health insurance, you are “gambling” with your health.  Here are the gambling statistics:

1.  Lack of health insurance causes 18,000 unnecessary deaths every year.

2.  Adults without health insurance have a 25% greater chance of dying from a disease or condition than those with health insurance.

Q.   If I don’t have health insurance and need medical care, won’t the hospital charge me less money because I am uninsured? 

A.   No. What many people do not know is that hospitals routinely charge uninsured people up to four times as much for medical treatment as patients with health insurance coverage. Insurance companies often
negotiate rates for their policy holders and hospitals agree to charge those patients a set dollar amount for medical care. The rate the hospital may charge an insured patient often differs from what the hospital will
charge an uninsured patient. The average uninsured patient will pay $30,000 for medical treatment related to a mild heart attack while an insured patient’s private insurance company will be charged less than
$10,000 for the exact same treatment. This means that the average, uninsured working man or woman can be stuck with a bill that is more than double what a managed care company or a government program
pays for medical treatment. In most cases, uninsured individuals are aggressively pursued by collection agencies for debts relating to medical care.  

Q.   How many Americans do not have health insurance? 

A.   In 2005, the number of uninsured Americans stood at a record 46.6 million, indicating that 15.9 percent of Americans lack health insurance coverage.  The ranks of the uninsured in 2005 included 21.5 million
people who worked full-time.  Census Bureau data shows that the number of uninsured has consistently increased over the last 5 years and more people are without health insurance now, than at any point in history. 
Today, more than 38 million Americans rely on Medicaid as a safety net for their care needs.  Since 2000, the ranks of the uninsured have grown by 6.8 million.  Additionally, data collected in 2005, also indicates
that the percentage of Americans with private health insurance declined to 67.7 percent. The percentage was 63.6 percent in 2000.  The data demonstrates that 3 million fewer Americans had employment-based
health insurance coverage in 2005, then in the year 2000. 

Q.   If I have health insurance do I still have to worry about bankruptcy? 

A.   Yes.  According to a recent Harvard study, nearly half of the estimated 1.5 million personal bankruptcies filed each year result from high health expenses—even though 76 percent of the filers are covered by
health insurance at the onset of illness. This report appears in the February 2007 issue of Health Affairs. According to David Himmelstein, an associate professor of medicine at Harvard Medical School who led
the study, "Almost every American is one step away from potential bankruptcy from serious illness." 

Q.   Why are so many Americans with health insurance coverage filing for bankruptcy?

A.   The primary reason is that policy holders really don’t understand their health insurance benefits and their total out of pocket expenses. To stay price competitive and make a larger profit,  health insurance
companies often eliminate or reduce benefits. Often, the way the policy is sold, this reduction in benefits may not even be noticeable. However, it is important to point out that some companies, in particular,
those that service the small business & self-employed health insurance market, have decreased lifetime benefits, limited coverage for organ transplants, implemented separate hospital deductibles, restricted
diagnostic & out-patient treatments and imposed access fees. Companies have even eliminated certain benefits entirely, for example, prescription drugs, organ transplants and maternity coverage. Let’s look
at how some companies have eliminated or reduced benefits for organ transplant coverage. A policy holder knows that s/he has a plan that offers coverage for organ transplants, but what s/he may not know
is that there is only a $100,000 maximum benefit for a procedure that normally costs $250,000-$500,000. Now let’s take a look at how a company can advertise that a policy has a $5 million maximum
lifetime benefit, when in fact, the benefit may only be $100,000 per illness. A consumer purchases a health insurance policy that offers $5 million maximum of lifetime benefits, however, in the “fine print” of
the brochure, the plan states that it has a $100,000 “per illness” cap. This means that if the policy holder develops a serious illness that requires only 1 surgery, his/her $100,000 “per illness” cap may be
reached by the time s/he has her 2nd surgery. Unfortunately, consumers don’t often read the “fine print” until their insurance company informs then that they have exhausted their coverage and the policy
holder discovers that the “affordable” health insurance plan with $5 million dollars of lifetime coverage won’t pay out  $5 million dollars unless the policy holder develops multiple unrelated & separate life-
threatening and debilitating illnesses all with a cost less than $100,000. Hopefully this should make it easier to understand why so many Americans with health insurance are forced to file for bankruptcy.

Q.   Won’t filing for bankruptcy eliminate all my medical debt? 

A.   A controversial bankruptcy law enacted by Congress in 2006, makes it tougher for many Americans to wipe out debt by declaring bankruptcy, regardless of whether their debt resulted from medical bills
or from reckless spending at the mall. Under the old law, people who filed for bankruptcy under Chapter 7 were allowed to erase their debt and start fresh. The new measure makes it less likely that debtors
particularly those who earn more than their state’s median income level—will qualify for Chapter 7.  Instead, they will have to file under Chapter 13, which requires paying off some or all debt over a designated
period of time. Filers must then go through a "means test" to determine how much debt, if any, they can pay. They must also get credit counseling and take a financial management course at their own expense.

Q.  I know I need health insurance, but can I really afford it?  

A.  Unfortunately, it is a fact of life that you may have to give up certain luxury items, brown bag your lunch or decrease your spending in other areas to afford health insurance.  If you are the type of person that
wouldn’t risk driving your vehicle without car insurance, consider the fact that there is a statistically greater chance that you will suffer from an illness or injury than an auto accident. Today, nearly 20 cents out of
every dollar spent in the United States is spent on health care. In 2006, the U.S. health care spending weighed in at $2.1 trillion and is projected to double to $4.1 trillion by 2016, according to John Poisal, deputy
director of the National Health Statistics Group, part of the Office of the Actuary in the Centers for Medicare and Medicaid Services, in a 2007 Health Affairs study.The report also predicts the annual growth
rate for prescription drug spending will soar from 7.4% in 2007 to nearly 10% in 2016.

Q.  Where can I buy a health insurance policy? 

A.  Traditionally, health insurance policies have been sold by “captive” agents who worked for insurance companies and had a vested interest in selling you that company’s insurance products. Today, there are
more consumer-friendly options for acquiring health insurance coverage. “Independent” insurance agents, also known as “non-captive” agents or “brokers” can sell insurance policies from several different companies,
allowing them to be more objective about your personal needs. These individuals may even be able to provide a complete review of your insurance needs, something you should do at least once a year to make sure
that your policy is up to date with your current financial situation. Finally, the web has become an excellent resource for comparison shopping, however, when purchasing insurance, consumers must keep in mind that,
although convenient, the web is no substitute for the personal attention that you will receive when you deal with a knowledgeable, ethical and reputable health insurance agent or “broker.” It does not cost a penny more
to purchase your insurance through an agent or broker so why buy blindly?

Q.   What is a “captive” agent?” 

A.   A “captive” agent is an insurance agent that works for one company and is restricted, by agreement, to only recommend and sell the insurance products that that particular company offers, even if those products
do not exactly meet the insurance needs of the customer. In essence, the “captive” agent has more of an allegiance to the insurance company than the insurance buyer. For example, if you walk into a State Farm office
to purchase health insurance that agent can only sell you Assurant Health products. Assurant Health products are some of the most expensive  health insurance products on the market today and they contain significant
additional out of pocket expenses. If you expect your insurance agent to provide you with several plan comparisons from different carriers, it is in your best interest to work with a knowledgeable, ethical and reputable
“independent” agent or “broker.”

Q.   What is a “non-captive” “independent” insurance agent or “broker?”

A.   A “non-captive” “independent” insurance agent or “broker” is a licensed professional representing the insurance buyer/consumer, rather than the insurance company. A “non-captive’ “independent” insurance agent
or “broker” usually represents more than one company, therefore, plan comparisons can be made and plan benefits can be added, based on the buyer’s specific insurance needs. Most insurance “brokers” also offer
multiple lines of insurance products including health insurance, life insurance, accident only policies, disability insurance, critical illness policies, long term care insurance, workman’s compensation insurance, business
insurance and certain financial services.

Q.  Should I choose to work with a “captive” agent or an insurance “broker?” 

A.   Ultimately, that choice is really up to you.  If you have been working with a “captive” agent who has been less than forthcoming about what your health plan does and does not cover or has not fully informed you
about your plan’s benefits, limitations of coverage and total out-of-pocket expenses, then it might be in your best interest to speak to a insurance “broker” to determine how your current plan’s benefits and price
compare to other plans on the market. If you are too busy to comparison shop, it is in your best interest to work with a knowledgeable, ethical and reputable insurance “broker.”

Q.   How do I find knowledgeable, ethical and reputable insurance “brokers?”        

A.   Knowledgeable, ethical and reputable insurance “brokers” often rely on “word of mouth” advertising. Many insurance “brokers” advertise in the yellow pages or on the web, but advertisements are no substitute
for good business relationships with existing clients.   Reputable “brokers” will usually have a web site that includes client testimonials. If a “broker” does not have a list of client testimonials, ask for a list of referrals.
In most states, insurance agents and “brokers” are licensed through the State Department (or Division) of Insurance. In Illinois, the Division of Insurance falls under the umbrella of the Illinois Department of Financial
and Professional Regulations (IDFPR). The Office of Consumer Health Insurance can tell you if your insurance agent is licensed and whether there have been any disciplinary actions taken against that individual.
You can call the Office of Consumer Health Insurance toll free at (877) 527-9431. The Illinois Division of Insurance also compiles statistics regarding the type of insurance complaints it receives and the reason for
the complaints. The IDFPR also collects complaint data against insurance companies. The number to the IDFPR is 312-814-2424.

Q.  What if the “broker” I am working with recommends that I buy a health insurance policy from a company that I have never heard of before?  

A.   If you are uncertain about your “broker’s” recommendation, take some time to do your own due diligence before making a purchasing decision.  It is your right to have all of your questions answered and to feel
completely comfortable with your purchasing decision before you sign on the dotted line. Today, more than ever, consumers have an overwhelmingly number of options when it comes to purchasing health insurance. 
If your “broker” works with many companies, chances are very likely that your “broker” may recommend a plan or a company that you have not heard of before. Just because a particular company doesn’t spend
tens of millions of dollars on T.V. and radio advertising, like Blue Cross/Blue Shield, Humana or United Health Care, does not mean that the company does not have sufficient reserves to pay claims. Before you buy
a policy from ANY insurance company, even if the name is highly recognizable, it is important to check out the company’s rating with a leading independent rating service, such as Standard & Poor's A.M. Best, Moody’s
or another reputable rating service. The company’s ratings will tell you whether the company is likely to be able to pay off claims in the event of a disaster or an abundance of payouts. If you are working with a reputable
insurance “broker,” who has had several policies issued with that particular company, your “broker” will be able to tell you what you can expect in terms of claims payments, speed of payout, and customer service.

Q.   How do I know if there have been any complaints issued against a particular insurance company? 

A.   In Illinois, the Office of Consumer Health Insurance offers consumers help if they have questions or concerns about their health insurance policy or a health insurance company. The office was established by the
Illinois Department (now Division) of Insurance on January 1, 2000, as part of the new Managed Care Reform and Patient Rights Act. The Office of Consumer health insurance can explain your rights as a health care
consumer, answer questions about health insurance, help you understand the coverage provisions of your specific health care plan and assist you when you have a problem or complaint. To contact the Office of
Consumer Health Insurance, call toll free at (877) 527-9431. The Illinois Division of Insurance also compiles statistics regarding the type of insurance complaints it receives and the reason for the complaints.
This information is available to consumers @ www.idfpr.com/DOI/Complaints/Complaints.asp. For general questions, you can email the Division of Insurance at director@ins.state.il.us.

Q.   What if my insurance company can’t answer my questions about my health insurance benefits or I have concerns about claims that have not been paid? 

A.   If you are not happy with the answers that your insurance company is giving you, have outstanding claims that have not been paid, or just generally feel like you are getting the run around, the first person you
should call is the insurance agent or “broker” that sold you your policy. Your agent or “broker,” should be able to work with you and your insurance company to resolve your insurance issues. If you can not resolve
your issues by working with your agent or “broker,” you can file a consumer complaint against the insurance company by completing a complaint form on the Division of Insurance web site. The form can be
completed and sent electronically or printed out and mailed to the Illinois Division of Insurance. Find the form here: www.idfpr.com/DOI/Complaints/file_complaint.asp.  When you make a complaint against
an insurance company or insurance producer (agent), the Division of Insurance will initiate an investigation, assign your complaint a file number and notify you of the results of their investigation.

Q.   I found out that my agent misrepresented the type of health insurance benefits I have and now my insurance company is refusing to pay claims that I thought were covered.  What should I do?

A.   First, you should talk to your agent to see if you if there anything that s/he can do to help you resolve your issue with your insurance company. If your agent is unable or unwilling to help you resolve your issue
with your insurance company, you can contact the Office of Consumer Health Insurance to ask for assistance. To contact the Office of Consumer health insurance, call toll free at (877) 527-9431. Depending on
the situation, the Office of Consumer Health Insurance may direct you to file a complaint against the insurance producer that sold you your policy, the insurance company that issued your policy or both.
The complaint form is available on the Division of Insurance’s web site www.idfpr.com/DOI/Complaints/file_complaint.asp. The consumer complaint form can be completed either electronically or in hard copy format.
When you make a complaint against an insurance company or insurance producer (agent), the Division of Insurance will initiate an investigation, assign your complaint a file number and notify you of the results of their investigation.

Q.   I was contacted by an insurance agent who informed me that I could only get health insurance at a cheaper price, if I joined an Association.  Is this true? 

A.  In many cases yes. Many quality products are endorsed and specifically designed to work with a reputable association. Often times an insurance company will design “private label” products specifically for
the members of a particular association. They do this to appeal the members of this association and to reap the premiums that would be inherent to enrolling an association comprised of many members. There is
one association you should be aware of and avoid. It is called the National Association of Self-Employed (NASE), a division of the MEGA Life and Health Insurance company and the Mid-West National Life
Insurance Company. You may get great association benefits, like discounts on office supplies, but what you may not get is adequate health insurance. This association targets unsuspecting business owners by
offering low price health plans with added benefits like discounts on office supplies and other products. Often, this association’s plans offer very limited benefits, resulting in enormous out of pocket expenses for
the buyer. According to the National Association of Insurance Commissioners (NAIC), N.A.S.E. has been the subject of 14 investigations by state insurance officials since 1995. If you are a business owner,
you have, most likely, been inundated with phone calls from telemarketers and insurance agents claiming to offer the very best health insurance plans at the cheapest price. Remember the caveat, “Buyer beware.”
If something sounds too good to be true, it probably is. Due your own due diligence and read the fine print!

Q.   I was approached by someone offering to sell me a health plan that offered discounts on medical, vision and dental care and prescription drugs. Is this the same thing as health insurance? 

A.   No. A health care discount plan is NOT health insurance however, some unscrupulous agents and non-agents have been known to misrepresent discount plans as health insurance plans.
To misrepresent a discount plan as an insurance plan or policy is a violation of state insurance regulations. To see if a drug, vision or health care DISCOUNT PLAN is registered with the Division
of Insurance in Illinois, refer to the Department of Insurance’s Preferred Provider Administrator List, available at www.idfpr.com/DOI/PPA/PPAlist.asp

Q.   How do I become an educated and informed insurance consumer?

A.   In Illinois, the Illinois Division of Insurance offers some excellent consumer resources on their web site. You can take an interactive online quiz to determine how much you know @ www.idfpr.com/DOI/Get_Smart_Week/2005/flashQuiz/web_quiz.html. To assist you in selecting a reputable insurance company, the Division also has a list of telephone contacts and web site links which can
help you determine if the company holds a certificate of authority (license) to do business in Illinois, is financially sound, and has a low rate of consumer complaints www.idfpr.com/DOI/General/find_reputable.asp.
The Division of Insurance also offers some good advice on how to watch out for insurance fraud www.idfpr.com/DOI/General/Fraud_facts.asp, so you don’t fall victim to an insurance scam or scheme.
Additional consumer information can be obtained from the National Association of Insurance Commissioners (NAIC) at www.naic.org/index.htm

Q.   How often should I review my health insurance coverage to see if my policy is meeting my insurance needs? 

A.   You should review your health insurance policy with your agent on a yearly basis to make sure that your plan still offers you adequate benefits and a price that that is comfortable for your current financial situation.
Most insurance savvy business owners know that even if you don’t file an insurance claim, insurance rates still go up. Insurance rates are usually adjusted on your policy’s anniversary. To keep your insurance rates
affordable, you may have to purchase another plan when rates go up. A good insurance agent or “broker” should contact you prior to your policy renewal date to notify you of your premium increase and to make
sure that your health insurance policy is still meeting your needs. If the rate increase is too high or if your agent believes s/he can find you a comparable plan at a lower price, you may have to apply for a new policy
which can go into effect before your rate increase occurs.

Q.   What is the process if I decide to obtain a health insurance policy? 

A.   After contacting a health insurance agent, the agent will gather some preliminary information about your medical history in order to prepare for you an insurance quote. 

The insurance quote should reflect any additional premiums you will be charged for certain medical or life-style conditions, such as obesity or smoking. The final quote should reflect the total amount of money you
will need to pay over the term of the insurance policy in exchange for coverage. Insurance policies are usually in effect for 1 year and are renewable upon your policy anniversary. If you agreed to pay the premium
amount to the insurance company, your agent will collect payment for a small application fee only. Once you are approved for said coverage and you accept their offer, the first month’s premium will be collected
on or about your requested effective date. You will receive a copy of your insurance policy which details the terms and conditions of your coverage shortly thereafter.

Q.   Does the law require all insurance companies to issue “individual” health insurance policies to anyone who applies?  

A.   No. Companies that issue “individual” health insurance coverage underwrite the applications prior to the policy being issued. Underwriting is based on many things including, but not limited to, age, health status,
occupation and certain hobbies. The company may (1) issue the policy as applied for; (2) issue the policy with stipulated exclusions either for a limited or unlimited period of time; (3) issue the policy with an added
premium; or (4) decline issuance of the policy. If a policy is issued other than as applied for, the company must provide a reason for offering exclusions or a declination, upon request.

Q.  I have chronic medical conditions, but I was recently told by an agent that s/he could “guarantee” me coverage on an “individual” health insurance policy.  Is this true?

A.   No.  If you apply for an “individual” health insurance policy, you will still have to go through an “underwriting” process.  If you have medical conditions, are currently receiving medical treatment or are extremely
obese, you may not receive an offer of coverage from the insurance company. If the agent told you that you would be “guaranteed” coverage, it is likely that the plan is nothing more than a discount plan that offers
you a discount on the cost of routine medical services. “Guaranteed” coverage is only available on “group” health insurance policies. You are never “guaranteed” coverage when you apply for an “individual”
health insurance policy. However, some states have a health insurance “risk pool” which guarantees coverage to individuals who have certain pre-existing medical conditions or who have been declined for
traditional health insurance coverage. In the state of Illinois this coverage is available through the Illinois Comprehensive Health Insurance Plan (I.C.H.I.P). Find out more about this coverage: http://www.chip.state.il.us/
 

Q.   What happens if an incident occurs and I have to file a claim for payment with my insurance company? 

A.   If an incident occurs that requires medical treatment, depending on the type of policy you have your insurance company may require that you 1. Pay the medical expense out of pocket and submit a claim to your
company for reimbursement or 2. Assign your insurance benefits (payment) to the treating physician or medical facility. In most cases, claims are automatically initiated by your medical provider and all you have to do
is present your insurance I.D. card at the time of claim. No payment is usually required up front other than a small co pay if it is an outpatient doctor’s office visit. Once your claim is processed, you will receive an
“explanation of benefits” or E.O.B., from your insurance company that details the total expenses of your medical treatment and lists the amount you owe.     

Q.   How long does an insurance company have to pay my medical claims?

A.   Once your claims have been received, the company has a reasonable time period in which they must either pay or deny a claim. If the claim is not paid within 30 days after the insurance company receives all
of the needed information about your claim, they must pay interest on the claim at the rate of 9% per annum.

Q.   What does a company mean by usual and customary charges?

A.    Usual and customary, also called reasonable and customary, means the fee amount charged by most of the providers in a given geographical area for a particular service. Insurance companies may subscribe
to an independent service which periodically surveys providers in a given area, or they may use their own claims experience to establish usual and customary allowances. Most companies pay claims based upon a
percentile of the usual and customary fee schedule.

Q.   My insurance company is delaying payment of my claim because they are checking for a pre-existing condition and are requesting information about all the doctors I have seen in the past 10 years. I know
the condition was not pre-existing, and this is just a waste of time. Can they do this?  

A.   Yes. The company is allowed to look back ten years to determine if treatment was received for a condition, or if symptoms were present that would have caused a prudent person to seek treatment for a condition.
Individual health insurance policies are allowed to exclude benefits for pre-existing conditions for the first two years the policy is in force. Some companies only exclude preexisting conditions for one year and only look
back for one year. This varies from policy to policy. A quality policy will pay for certain controlled pre-existing conditions such as Hypertension & Hyperlypidimia from day one providing they are disclosed at the time
of application. If a claim is submitted to the company within the pre-existing exclusion period, a pre-existing condition investigation will most likely take place. Note: Any condition that has been excluded by a rider may
be excluded for the life of the policy. Please refer to question Number 2 for more information. If you believe the company has taken too long to complete the investigation, you may file a complaint online with the
Division of Insurance www.idfpr.com/DOI/Complaints/file_complaint.asp.   Be sure to provide copies of any correspondence received from the company, as well as a copy of the insurance contract. We will contact
the company to find out why the claim is being delayed, and see if anything can be done to expedite the process.

Q.  My insurance company has rescinded my health insurance coverage. What exactly does that mean? 

A.   Illinois law permits insurance companies to rescind a health insurance policy under certain circumstances. An insurance policy is issued based on information contained in the application or enrollment form.
When an individual fails to completely and accurately disclose health information, including weight and height, on the application, it affects how the policy would have been issued. The company may have issued
the policy with an exclusionary rider, issued the policy for a higher premium, or declined coverage altogether had they been provided with correct information. Insurance companies will generally review the
application for accuracy and completeness when they receive the first claim. If they find an error or omission that is material (one that would have changed their offer of coverage) the company will take action to
rectify the situation. They may issue an exclusionary rider for the health condition in question and ask that you accept it as part of the policy. Or, if the error or omission is significant enough, the company may
rescind the policy and return your premiums to you less any claims paid out. Rescission means that the policy will be null and void from the beginning. They may also offer you the opportunity to pay the extra
“load” that they would have applied to the policy had they know about the pre-existing condition thereby keeping your policy in force. It is most important to fill out your application accurately and completely
to avoid having your policy rescinded or the original offer modified. When you receive your policy, check your copy of the application in the back of the policy to be sure that information was accurately recorded
if you did not fill out the application personally.

Q.   How do I know if my health insurance policy offers me sufficient coverage and that I am paying a fair price for my monthly premiums?  

A.   Most people who shop for insurance can not distinguish the difference between the benefits they “need” and the benefits they “want.”  If you were to purchase a health insurance plan with every benefit that
you can imagine, you many have great coverage, but the monthly premiums are bound to put a significant drain on your finances. If you don’t have disposable income; you won’t be able to afford health insurance
coverage for very long. If you are perfectly healthy and don’t take any medication, it may be in your best interest to select a plan with a higher deductible and a discount prescription card to keep your monthly
premiums lower. Set some money aside each month just in case an illness or injury occurs and you to pay your deductible or buy expensive prescription medications.

If the worst happens, you are financially prepared, if it doesn’t, that money is still yours to keep. Since there are so many plan options available from different insurance companies, your insurance agent should be
able to provide you with several plan options from different carriers that meet your insurance needs. Ultimately, it is up to you to make certain that you understand your insurance coverage. The Illinois Division of
Insurance web site offers many tips to help you ask the right questions so you understand your health insurance purchase. Visit their site here: www.idfpr.com/DOI/Main/consumer_info.asp.  

Q.   What kind of health plan should I select if it is likely that I will need medical treatment? 

A.   Firstly, if you have received medical treatment already for this condition or a doctor has diagnosed you with a particular condition in which medical treatment is needed the chances are likely that you will not
be approved for health insurance on an individual basis anyway. However, if your family history shows that you may be more susceptible to a particular illness and or you are getting older, it may make sense to
select a health insurance plan with a lower deductible. However, your monthly premiums will be significantly higher. Remember, if you opt to pay a higher monthly insurance premium and you do not need medical
treatment, you do not get any portion of higher monthly premiums that you paid to the insurance company back. There is no refund for remaining perfectly healthy.

Q.   Why do most insurance agents recommend health insurance plans with very low deductibles, like $250 or $500?  

A.   Simple, plans with lower deductibles cost more. Since insurance agents are paid a percentage based upon the amount of premiums collected, lower deductible plans mean a bigger paycheck for the agent.
Fortunately, not every insurance agent acts in their client’s best interest. Reputable, ethical and knowledgeable insurance agents and “brokers” usually have a long track record of doing what is in their client’s
best interest, even if it means less of a commission. A reputable agent will take the time to understand your insurance needs and explain what your policy does and does not cover.

Q.  What is an “individual” health insurance policy?

A.   An “individual” health insurance policy is a policy that provides insurance coverage for an individual or an individual and their dependants.

Q.  Who purchases “individual” health insurance policies? 

A.   In most cases,” individual” health insurance policies are purchased by independent contractors, freelancers, small business owners, entrepreneurs, and individual employees who work for a company that
doesn’t offer any health insurance benefits.

Q.  If I apply for “individual” health insurance, is coverage also available for my entire family? 

A.   Yes.  If you are applying for coverage for your family, each family member should be listed on your application when you apply for coverage.  

Q.  How much are the premiums for “individual” or “family” health insurance coverage? 

A.  Premiums are determined by a variety of factors, such as, the applicant(s) age at the time of application, the applicant(s) health history, if the applicant(s) smoke, if the applicant(s) take medications, etc.
Premium amounts are also largely dependant on the type of health plan selected, for example, plans with lower deductibles and lower out-of-pocket expense cost more. Plans that offer maternity coverage
cost more than plans that do not. 

Q.   What type of coverage does an “individual” health insurance policy provide? 

A.   “Individual” health insurance policies typically provide coverage for major medical expenses, such as doctor’s visits, hospital stays, surgery, out-patient therapy, diagnostic testing, prescription medications,
organ transplants, durable medical equipment, mental health counseling, emergency room services, ambulance service and other medical expenses.

Q.  What types of “individual” health insurance plans are available? 

A.   Many different types of health insurance can now be purchased directly by consumers.  These plans include, Traditional Major Medical Plans, Catastrophic Health Plans, H.S.A. (Health Savings Account)
qualified H.D.H.P’s (High Deductible Health Plans) Accident Only Plans, Catastrophic Illness Policies, Prescription Medication Plans, Dental Plans, Vision Plans and many others.

Q.   Which companies offer “individual” health insurance policies? 

A.   The majority of health insurance carriers offer some type of “individual” health insurance plan. 

Q.   If I purchase an “individual” health insurance plan, how are my rates determined?

A.   When you apply for health insurance, your rates are determined by a variety of factors: 

            1.   Your age at the time of application

            2.   Your overall health at the time of application                                                             

            3.   Your health history prior to application

            4.   Your status as a smoker, non-smoker or ex-smoker

            5.   Your weight (e.g. underweight, overweight, obese)

            6.   The types of medication(s) you are taking

            7.   The medication(s) you have taken in the past

            8.   Your current mental health status (e.g. depression or anxiety)

            9.   Your prior treatment for mental health or addiction

            10. Your occupation (e.g. attorney, pilot)

            11. The city, state and zip code in which you reside

            12. The health plan and benefits that you select (e.g. low deductible, maternity)

            13. Other factors that may be considered by underwriting

Q.  If I purchase an “individual” health insurance plan for my family, are my rates affected by the health condition of one of my family members?

A.  No.  Your portion of the monthly premium is not affected by the health history of other family members who may have poor health. However, your portion of the premium will  be calculated separately
from your family members. “Family” premiums are calculated by adding the premium costs for each family member. For example, if you are a healthy, M/30 year old non-smoker, your portion of the monthly
insurance premium may be $100. However, if you wife is ten years older F/40, slightly over-weight and a smoker, her portion of the premium may be significantly higher, $200.  If you have two young children
on your policy, M/10 and F/6, who are healthy, their monthly insurance premiums may be $50 each. The insurance company will then combine all of these premium amounts to determine your family’s total
monthly premium: (M/30 non-smoker = $100 + F/40 over-weight smoker = $200 + M/10 = $50 + F/6 = $50) The Total Monthly Family Premium = $300 ($100 + $200 + $50 + $50)

Q.   Can I still buy individual health insurance if I have a very serious pre-existing medical condition?

A.   In most states you can be turned down for individual health insurance coverage if you have a very serious medical condition (e.g., HIV or cancer). Fortunately, even though they are not required to do so,
most states have developed some way to provide uninsurable people with access to individual health insurance coverage. Thirty-three states provide coverage to medically uninsurable people through high-risk pools.
Twelve states use other means of providing uninsurable people with access to individual coverage (e.g., requiring that all individual health insurance companies issue individual health insurance policies regardless of
health status, coverage through a designated health insurance company of last resort, etc.). There are five states that still have no means of providing individual health insurance access to people with catastrophic
medical conditions. To find out what your state's options are for medically uninsurable individuals, check out the Health Care Coverage Options Database provide by the National Association of Health Underwriters (NAHU)

www.nahu.org/consumer/healthcare/topic.cfm?catID=23

Q.  What kinds of coverage is available for the medically uninsurable individuals?

A.   Different states have adopted different means of providing access to individual market coverage for people who have a catastrophic medical condition.  A brief outline of the resources available is outlined in the
following section: and they are all described in this section:

1.  Guarantee Issue Requirements
A few states require all individual market health insurance carriers to offer products to all people at any time, regardless of their health status, but most do not and instead offer the general public another
alternative such as a high-risk pool. However, all states have to have at least one means of providing guaranteed-issue coverage to individuals exercising their federally mandated group-to-individual rights.
It can be through the traditional private market, through a high-risk pool, or through another means. This section covers all of these state-specific provisions.  Please use the link to locate the requirements
of your particular state. www.nahu.org/consumer/healthcare/topic.cfm?catID=117

2.    High-Risk Health Insurance Pools
The most common way states provide people with serious medical conditions with access to private individual health insurance coverage is through the creation of a high-risk health insurance pool.
Consumers in these pools have access to comprehensive private coverage plans, but pay slightly more than the average individual market premium due to their health conditions. This section provides an
overview of each state high-risk pool, including eligibility requirements, rate restrictions, preexisting condition requirements, covered services, cost information and contact information. Please use the link
to locate the requirements of your particular state. www.nahu.org/consumer/healthcare/topic.cfm?catID=120

3.  High-Risk Reinsurance Pool
Another option for providing access to private individual market coverage to people with serious medical conditions is a high-risk reinsurance pool. A reinsurance pool has many characteristics that are
similar to a high-risk pool, but the individual purchaser does not buy their policy directly through the pool. Instead they buy their policies from individual insurance carriers, who then cede the high-risk
policies to the pool for risk spreading.  Please use the link to locate the requirements of your particular state. www.nahu.org/consumer/healthcare/topic.cfm?catID=127

Q.  Do “individual” health insurance policies include any additional benefits? 

A.  Yes.  Some “individual” health insurance policies include optional benefits (optional riders) that can be added onto your health insurance policy for additional protection.  The following is a list of “optional riders”
that your health insurance company may allow you to add onto your health insurance policy for an additional premium amount:

            1.  Life Insurance (amount determined at time of application)

            2.  Accidental Death and Dismemberment

            3.  24 hour accident coverage (on or off the job)

            4.  Maternity

Q.  What are the advantages of purchasing an “individual” health insurance policy?

A.  There are three major advantages to purchasing an “individual” health insurance plan is “Price, Portability and Guaranteed Renewability.”

1.  Price – In most cases, price is a major issue in determining what health insurance plan to purchase. “Individual” coverage is usually significantly lower than “group” coverage.

2.  Portability – When you purchase an “individual” health insurance plan, your plan is completely portable, in that you can take it with you if you change jobs or residences.

3.  Guaranteed Renewability – As long as you keep paying you monthly premiums, your health insurance plan is renewable on the anniversary date of your policy.  Once your policy has been approved,
your coverage will continue no matter how sick you get or how many claims you file.

Note:  Although your insurance company can not increase your insurance premiums because you file a claim for benefits, they can raise your rates incrementally during the lifetime of your policy. Most insurance
companies will adjust your insurance rates higher, on the one year anniversary of your policy. Other companies will make a rate adjustment on your 6 month and one year policy anniversary. Insurance companies
usually increase premiums a certain percentage each year.  On average, “individual” policy holders experience a 10-30% premium increase each year. 

Q.   How are initial “individual” premium rates determined if the insurance company is unable to obtain important medical information from my doctor?

A.   In the vast majority of states, when you apply for individual health insurance coverage, you are asked to provide health information about yourself and any family members to be covered. When determining rates,
insurance companies use the medical information on these applications. Sometimes they will request additional information from an applicant's physician or ask the applicants for clarification.  If the insurance company
is unable to obtain information necessary to accurately determine the risk of a particular applicant, it will underwrite more conservatively, meaning that the assumption relative to the missing information will be negative
rather than positive.

Example: A person has a history of high blood pressure, but it is controlled with medication and he is not overweight. If the company is unable to determine if that individual smokes or if he has normal cholesterol,
the company will assume that the missing information is negative and rate accordingly.

Q.  How are rate increases (premium increases) calculated for “individual” health insurance policy holders?

A.  There are complex formulas that insurance actuaries (number crunchers) use to calculate rate increases.  Insurance companies take many factors into consideration:

1.  The number of policy holders in a given demographic area (zip code)

2.  The amount of claims filed by policy holders

3.  The type of claims filed by policy holders

4.  The amount that the insurance company paid out in plan benefits

5.  Other factors determined by the actuaries

Q.  Does every “individual” policy holder in my zip code receive the same percentage of a rate increase?

A.  Yes.  Once the company has determined your health status, you will be assigned a rate class by the company and put into a pool of other insured individuals with similar health status. Your premium will be the
rate charged to that entire class of customers. Subsequent annual renewal premium rates will be determined not by your individual claims, but instead by the claims experience of the entire rating class pool. It is
against the law for an insurance company to single out an “individual” policy holder for a significantly higher rate increase, because that policy holder filed a substantial amount of claims with the insurance company.

Q.  How do I apply for an “individual” health insurance policy? 

A.  You can apply for an “individual” health insurance policy directly through an insurance company or through an insurance agent. If you apply for an “individual” health insurance policy directly through an insurance
company, you choices will be limited to that health insurance plans available through that company. Although the web is a great place to comparison shop, it is in a consumer’s best interest to contact a knowledgeable,
ethical and reputable insurance agent or “broker” before making a purchasing decision.

Q.  If I have an “individual” health insurance policy, can my insurance company raise my rates if I file a claim?

A.   No. If you have an “individual” health insurance policy and file a claim for benefits with your insurance company, the insurance company can not arbitrarily increase your insurance premiums just because you filed a claim. 

Q.  What is the maximum rate increase I can receive if I have an “individual” health insurance policy?

A.  Currently, there are no restrictions on how much an insurance company can raise your health insurance rates upon your renewal date. The average premium increase you can expect per year is 10-30%, however,
it is not uncommon for rates to double or even triple. 

Q.   I had knee surgery last year. The insurance company will issue me a policy, but refuses to cover anything that happens to my knee. They have asked me to sign an exclusion rider that states there will be no coverage
for anything that happens to my knee. Can the company do this?

A.   Yes. Insurance companies may attach an exclusion rider to the policy that specifies that benefits will not be provided for any loss that results from the condition specified in the rider. In this example, the rider may
exclude any claim for injury, disease or disorder to your knee.

Q.   Do exclusion riders continue for the life of the policy? 

A.   In most instances, the exclusion rider is attached for the life of the policy. In some instances, the rider will state that it may be reviewed at some time in the future (usually one to two years). Depending on the
severity of your medical condition and the likelihood that your condition will someday reoccur, some “exclusionary riders” may be placed on a policy for an indefinite duration. 

Q.   Is a “rider” automatically removed by the insurance company after a certain period?

A.   No. If your “rider states that it can be reviewed sometime in the future (usually two years), it is up to you as the policyholder to request the review. The rider will not be automatically reviewed or removed by the company.

Q.   How will I know if my “pre-existing” condition will receive a “rider?” 

A.   If you have a knowledgeable health insurance agent who is familiar with the underwriting process, s/he should be able to tell you whether or not your “pre-existing” condition will receive a “rider.” 

Q.   Do all insurance carriers “rider” the same “pre-existing” conditions?

A.    No.  Some insurance carriers are more liberal than others in their underwriting process. Just because a “rider” was placed on your “pre-existing” condition by one insurance carrier, doesn’t necessarily mean
that you will always receive a “rider” every time you apply for “individual” health insurance coverage.

Q.   If I have “pre-existing” medical condition, can my employer “exclude” me from participating in a “group” health plan or charge me more for my coverage? 

A.   No. There are certain discrimination prohibitions in HIPPA law that ensure that individuals are not excluded from coverage, denied benefits, or charged more for coverage offered by a plan or issuer, based on
health status-related factors.

Q.   If I am refused a policy or it is not issued as applied for, how can I find out why?

A.   You must make a written request to the insurance company. They are required to inform you of the reason(s) for their decision. Or if your agent has an established relationship with an insurance company’s
underwriters he or she may be able to find out for you. If the reason is based on medical information, the insurance company may request the name and address of the doctor to whom you would like the information sent.

The doctor then would explain the medical reason for the adverse outcome.

Q.   What is a “pre-existing” condition? 

A.   The law defines a “pre-existing” condition as one for which medical advice, diagnosis, care, or treatment was recommended or received prior to an individual’s enrollment date (which is the earlier for the first day
of health coverage or the first day of any waiting period for coverage).

Q.   If I apply for “individual” health coverage, will my “pre-existing” condition(s) be covered?

A.   Maybe. Some conditions, if present at the time you apply for health insurance may be automatically covered. The better companies will cover certain controlled pre-existing conditions such as Hypertension &
Hyperlypidimia from day one providing this is disclosed at the time of application. Whether or not your “pre-existing” condition(s) are covered under your “individual” health plan vary depending on the type of health
plan you apply for and the insurance company you purchase it from.

Q.   How will I know if my “pre-existing” condition(s) are covered on my “individual” health insurance plan? 

A.   When you apply for “individual” health insurance, you automatically go through a process called “underwriting.” During the underwriting process, an individual who works for the insurance company, known as
an underwriter, reviews your health history to determine your “insurability.” If you are relatively healthy, the insurance company may not be overly concerned about your “pre-existing” condition(s). However, if it’s
likely that your “pre-existing” condition may need medical treatment in the future, the underwriter will either rate your premium slightly higher or exclude your “pre-existing” condition. 

Q.   Do individual policies pay for prescription medications?

A.   You need to read your policy carefully. Some policies do not pay for any prescription medications; some pay for only those medications administered while confined in a medical facility; some pay a percentage
of the actual charge; and some policies provide a drug card which enables you to purchase prescriptions for a specified co-payment amount, such as $15.00. Other policies include a discount prescription card only.

Q.   Can I return my policy if I am not satisfied with it?

A.   When a policy is issued to you, you will have a "free look" period of at least 10 days to review the policy and make certain that it meets your expectations. If you are not satisfied with the policy, you may return
it within the 10-day period and request a full refund of the premium. To avoid any delay or confusion, return the policy directly to the company by certified mail within the "free look" period.

Q.   Can my insurance company require me to get approval prior to receiving medical services?

A.   Often individual health insurance policies will require pre-certification prior to a scheduled hospital stay or within a short period of time following an emergency admission. There may be other requirements or
restrictions in your policy. Be sure you understand the requirements of your policy.

Q.   What is a “Deductible?”  

A.   A “deductible” is the amount of covered expenses you must pay before the insurance company will pay for any of the covered medical expenses. Check carefully to be sure you understand exactly how the
deductible works before buying a policy. There are a number of ways deductibles may be administered by the company. Some policies apply the “deductible” to covered expenses on a per person, per calendar
year basis. If the policy is a family policy, there is normally a maximum number of deductibles per family per year, and sometimes a single deductible for a common family accident. Some policies apply the deductible
per medical condition or cause. This type of deductible can cause a single individual to pay several separate deductibles in a calendar year. Policies with this type of deductible may not have a maximum number of
deductibles to satisfy in a calendar year. These policies normally have a lower premium than those with a calendar year deductible.  Some policies apply the deductible for each hospital confinement separated by a
specified number of days (usually 60 days).

Q.  What is Co-insurance?

A.   Co-insurance is the percentage of expenses that you “split” with the insurance company after you pay your plan deductible. Most health insurance plans are designed to have the policy holder pay some percentage
of his/her medical costs up to a certain dollar amount of medical bills. This amount is known as the “stop loss.” Once the “stop loss” is reached, the insurance company will provide coverage at 100%, unless your plan
states that you are also responsible for additional deductibles and fees. Most plans are identified by their “co-insurance” percentage. For example, 100% (rarely seen), 90/10, 80/20, 7030 or 50/50. The first number,
identified in the split (80/20) is the percentage your insurance company pays after your deductible is met for that calendar year. The second number identified in the split (80/20) is the percentage you pay after your
deductible is satisfied. The maximum dollar amount that you will pay, depends on your “stop loss” dollar number. For example, on an 80/20 of $5,000 (stop loss), your co-insurance percentage is 20% of $5,000
which equates to ($1,000). On a 90/10 of $20,000 (stop loss), your co-insurance percentage is 10% of $20,000 this equates to $2,000.  

Q.  Does every health insurance plan have a “stop loss?”

A.  No. Some plans require you to pay a “co-insurance” for all your medical expenses. If you have an 80/20 plan with no “stop loss” and your medical bills for example, total $500,000. Your co-insurance amount will
be 20% of the total charges (20% of $500,000) or $100,000. 

Q.  How do I know if the health insurance plan has a “stop loss?”

A.  The “stop loss” should be outlined in the plan brochure that you received from the agent. If you have already have a health insurance policy in force, your insurance policy is required to provide an outline of coverage
and benefits usually on page 3 of your policy.

Q.   How do I determine the maximum out-of-pocket expenses I have to pay each year on my health insurance plan?

A.   Health insurance policies have a provision called an out-of-pocket maximum that limits the amount you must pay in a given benefit period, usually a calendar year. For example, if you purchased an 80/20 of $10,000
with a $1,000 deductible and you incur $51,000 in covered charges, your maximum out-of-pocket expenses are as follows:

Cost: $51,000 (total covered medical bills incurred)

You pay: $1,000 (your plan deductible)

Balance: $50,000
You pay: $2,000 (20% of the charges up to $10,000)
Insurance pays: $8,000 (80% of the charges up to $10,000)

New Balance (after co-insurance is “split” between you and your insurance)

 $40,000

Insurance pays: $40,000 (100% of the remaining charges)

Your total out-of-pocket maximum = deductible ($1,000) + co-insurance ($2,000) Your maximum out-of-pocket expenses per calendar year = $3,000

 Note: Not everything accrues toward the out-of-pocket maximum. For example, costs for excluded items, co-pays and any amount that is over the “usual and customary” determination, do not accrue toward
your out-of-pocket maximum. Additionally, some health insurance policies require you to pay a separate hospital deductible for each hospital admission and emergency room visit and many plans require that
you pay a separate yearly deductible for prescription medications. Other plans require you to pay separate co-pays or access fees for specific medical services, such as, out-patient physical therapy, speech therapy,
out patient surgery, chemotherapy and dialysis. In some cases, these deductibles, co-pays and access fees may be unlimited, in that, there is no “cap” of what you will be required to pay out-of-pocket if these
treatments become medically necessary.

Q.  If I purchase an “individual” health insurance policy, what is the lifetime maximum the insurance company will pay if I become seriously ill? 

A.   That really depends on the type of “individual” health plan that you select. Most “individual” health insurance plans have a $1 million, $2 million, or $5 million lifetime maximum. HMO’s, usually, have an unlimited
lifetime maximum. Note:  Some plans now impose a “per illness” cap, often times only $100,000 per illness. If an illness exceeds $100,000 then coverage for that illness is exhausted, regardless of the total lifetime
maximum amount of the policy. Consult your agent for more info. about “per illness” caps.

Q.   Is maternity coverage automatically included if I purchase an “individual” health insurance policy?

A.   No. Very few “individual” major medical plans offer normal pregnancy benefits as an optional coverage. Coverage for complications of pregnancy is a required benefit for all individual major medical plans
currently issued in the state of Illinois for example. Although normal maternity benefits may be offered as an option, the benefits are usually on a graduated scale based on the length of time the policy has been in
force. Sometimes individual health insurance policies have a sliding scale for the percentage for this benefit. It may pay nothing the first 12 months of the policy, 50% between 13 and 24 months, 65% from 25 to
36 months, and 80% after 37 months. Before accepting a policy, be sure you are clear as to how the benefit applies to you.

Q.  If I have an “individual” health insurance plan that does not include “maternity” coverage, how can I possibly afford to pay for my pregnancy and delivery on my own? 

A.   Many hospitals and OB/GYNs offer affordable pre-payment plans for pregnancies and deliveries. Some plans will allow you to pay a set monthly amount during your pregnancy and a larger fee right before
your delivery date. These fees customarily will cover all prenatal care and a normal vaginal delivery.  However, some medical services, such as pre-natal ultrasounds, amniocentesis and genetic testing may not be
included. These medical services, will, most likely, have to be paid out-of-pocket. If you don’t have a health insurance plan that provides coverage for “maternity” you should speak to your doctor as soon as you
discover that you are pregnant. You and your doctor can determine what care you will need and what costs involved. If you are a low income expectant mother without “maternity” coverage, you may qualify for
the State of Illinois FAMILYCARE program (formerly KIDCARE). FAMILYCARE insures expectant mothers who meet income requirements. For information call the FAMILYCARE hotline toll-free at
800-ALLKIDS (255-5437). Or you can visit them on the web @ www.familycareillinois.com

Q.   If I don’t have health insurance coverage during my pregnancy, can I immediately insure myself and my infant as soon as s/he is born?

A.  No.  There is a two week waiting period before you can qualify for “individual” health insurance coverage. Usually, you can apply for coverage, right after your two week, post partum check-up. You can apply
for coverage for your infant after your child’s six week check-up. Whether or not you and your infant are “insurable” depends on your health status at the time of application.

Q.  Can I purchase an “individual” health insurance plan that provides “maternity” coverage if I am already “pregnant?” 

A.  No. You can not purchase an “individual” health insurance plan if you are already pregnant. You may, however, qualify for coverage under the State of Illinois FAMILYCARE program (formerly KIDCARE)
FAMILYCARE insures expectant mothers who meet income requirements. For information call the FAMILYCARE hotline toll-free at 800-ALLKIDS (255-5437). Or you can visit them on the web
@ www.familycareillinois.com

Q.   If I have an “individual” health insurance policy that doesn’t have “maternity” coverage and I give birth, is my infant automatically covered as soon as s/he is born? 

A.   No, you have a 31 day window from the time your infant is born to add your child on to your health insurance policy without proof of insurability. If you do not add your new baby on to your health insurance
plan within the 31 day window and your baby has a birth defect, a life-threatening illness or a medical condition, the insurance company can “decline” to add your child onto your “individual” health insurance policy.

Q.  If I have an “individual” health insurance policy that does not include “maternity” coverage and I have to have an emergency C-section, will my C-section surgery be covered by my health insurance plan? 

A.  Yes, an emergency C-section is considered a “complication of pregnancy” and is normally covered under most health insurance plans, even if you have not added “maternity” coverage to your policy unless
your existing policy has an exclusion rider due to the fact that you have had a C-section prior to the issuance of your existing policy.

Q.   How can I find health insurance for my children if I don't have family coverage?

A.    Some insurance companies will issue policies to children without their parents being included on the policy. If your children are not insured for financial reasons, they may qualify for coverage under the
State of Illinois ALLKIDS program (formerly KIDCARE) ALLKIDS insures the children of parents who meet income requirements. For information call the ALLKIDS hotline toll-free at 866-ALL-KIDS
(255-5437). Or you can find them the web @ www.allkidscovered.com

Q.   How is “individual” health insurance different from “group” insurance?

A.   Individual health insurance is very different than group health insurance, which is the type of insurance that is offered through an employer. Since laws mandating what types of services must be included in
individual health insurance policies are often different than those dictating what must be included in group policies, benefits are generally less extensive than what most people would receive through coverage they
have through work. Individual consumers may be surprised to learn that some benefits that may be considered “standard' in a group policy, like maternity coverage or substance-abuse treatment, may not be
included in an individual health insurance plan. Sometimes individual health insurance consumers have the option to pay extra for coverage of additional services like maternity coverage. This extra coverage is
referred to as an optional rider.  Cost is often the primary factor for individual health insurance consumers, which is another reason why the benefits included in individual health insurance policies are often simpler.
In addition, deductibles (the amount you have to pay before insurance benefits begin) and cost-sharing (the fees you pay directly to medical providers at the time of service) are also generally higher.  Individual
health insurance companies are much more limited than group insurance companies in their ability to spread risk, so the laws concerning individual health insurance are different in most states. This means that
applicants for individual insurance will need to complete a brief medical questionnaire when applying for benefits and, unlike a group insurance policy, in most states a company can decide not to cover people
with very serious medical conditions (e.g., HIV or cancer), deeming them “uninsurable.”

Q.  What is a Health Savings Account (H.S.A.)?

A.  Health Savings Accounts (H.S.A.'s) are a new way for consumers to pay for medical expenses. As of January 1, 2004, almost anyone with a qualified High Deductible Health Plan (H.D.H.P.) can also have a
Health Savings Account. H.S.A.’s can save you money on your medical care now as well as provide a good way to save for future medical expenses. H.S.A. funds can pay for expenses before you meet your
deductible as well as helps pay for services not covered by your health plan, COBRA coverage during periods of unemployment, medical expenses after retirement and long-term care expenses, to name just a few.
H.S.A. funds can be used to pay for expenses that insurance companies would not normally cover such as Radiokeratonomy (Lasik eye surgery) Orthodontia, & Alternative Medicine to name just a few. If you use
your H.S.A. funds to pay for these expenses they will be a 100% tax deduction. Your high-deductible health plan can be one you get through your employer or a policy you buy on your own. Even if you get your
high-deductible health plan or even your H.S.A. account through your employer, you own your account. You decide how much to contribute, how much of the account to use for medical expenses, and which
medical expenses to pay from your account. You also choose whether to pay for medical expenses from the account or save it for future use. Even if you change jobs, your Health Savings Account is still yours.
You can keep the account even if you move to another state, and you can continue to keep it as you grow older. Regardless of where you get your health insurance plan, whether on your own or through your
employer, your Health Savings Account funds are yours. Unlike some other types of accounts, you don't lose H.S.A. funds at the end of the year. Unspent balances remain in your account earning interest until
you spend them on medical care. You may even roll your unused H.S.A funds into no load mutual funds potentially earning an even higher rate of interest. This will be a strong incentive for you to spend wisely
on your medical care, just like you do on other items you purchase. You'll want to shop around for the best value for your health care dollars.
To learn all about H.S.A.’s please Click here: Small Business Insurance Services-What are H.S.A.'s and H.D.H.P.'s and how can they save you money

Q.  What is a “group” health insurance policy?

A.   A “group” “group” health insurance policy is an insurance policy purchased by an individual that is “eligible” to participate in their employer’s sponsored health insurance plan.

Q.  Who purchases a “group” health insurance policy? 

A.   In most cases, a “group” health insurance policy is purchased by an employer/company that would like to offer health insurance coverage as a benefit to employees.

Q.  If I apply for “group” health insurance, is coverage also available for my entire family? 

A.   Maybe.  Ultimately it is up to your employer to determine whether your company’s “group” health insurance plan will allow you to enroll your dependants. 

Q.  What are the premiums for “group” or “family” health insurance coverage? 

A.  Premiums for “group” health insurance are usually determined by a variety of factors, such as, the age of the applicant(s) at the time of application, the health status of the individuals/family members
(if applicable) applying for “group” coverage, how individuals in the “group” smoke, the number of individuals that are on maintenance medications, etc. Premium amounts are also largely dependant on the type of
health plan selected; for example, plans with lower deductibles, doctor co-pays and full prescription plans will be more costly than plans with a higher deductible, no doctor co-pays and a prescription discount card. 
Additionally, “group” health plans that offer maternity coverage cost more than plans that don’t. 

Q.   What type of coverage does a “group” health insurance policy provide? 

A.   “Group” health insurance policies typically provide coverage for major medical expenses, such as doctor’s visits, hospital stays, surgery, out-patient therapy, diagnostic testing, prescription medications,
organ transplants, durable medical equipment, mental health counseling, emergency room services, ambulance service and other medical expenses.

Q.  What types of “group” health insurance plans are available? 

A.   Many different types of health insurance plans can now be purchased by employers.  Often, employers will give employees a choice of several health plans, so they can choose a plan that meets their insurance
needs and budget.  These plans include, Traditional Major Medical Plans, Health Savings Accounts or HSA’s, Accident Plans, Catastrophic Illness Policies, Prescription Medication Plans, Dental Plans, Vision Plans
and many others.

Q.   Which companies offer “group” health insurance policies? 

A.   The majority of health insurance carriers offer some type of “group” health insurance plan. 

Q.   When I participate in a “group” health insurance plan, how are “group” rates determined?

A.   Carriers often base rates on group size, group’s case characteristics, such as, age, gender, industry, demographic area, plan design and risk characteristics.  The rating process for a group is usually a two-step process:

1.  First, a premium rate is determined based on the group case characteristics and plan design factors (copays, deductibles, out of pocket maximums, etc.) but without regard to other risk characteristics.

2.  Second, the rate may be adjusted by a "risk load" to reflect risk characteristics of the group. Risk characteristics include health status-related factors, the duration of coverage, and any other characteristics
related to the health status or experience of a small employer group or of any member of a small employer group. The risk load adjustment must apply uniformly to all members of the group. Initially, when an
employer is first issued a policy, the risk load may be as high as 67 percent.

Q.  How much will my rates increase if I participate in a “group” health insurance plan?

A.   No more than 15% per 12-month period. The risk load may be increased at renewal by no more than 15 percent per 12-month period (pro-rata for periods less than 12 months). This 15 percent maximum applies
to the risk load portion only. Increases due to other factors such as changes in plan design or changes in case characteristics may be in addition to any increase in the risk load. This does not take into consideration any
changes in plan design or changes in case characteristics.

Q.  If I purchase a “group” health insurance plan for my family, are my rates affected by the health condition(s) of one of my family members?

A.  If your employer is starting a new “group” health insurance plan and you add a dependant onto your “group” health insurance plan that has a serious medical condition, the insurance carrier can apply a risk load
adjustment that results in a premium increase for everyone in the group. This adjustment could be as high as 67 percent if several individuals in the group have serious medical conditions.                                                        

Q.  Does a “group” health insurance policy offer any additional benefits? 

 A.  Yes.  Some “group” health insurance policies include optional benefits (optional riders) that can be added onto your health insurance policy for additional protection.  The following is a list of “optional riders” that
your health insurance company may allow you to add onto your health insurance policy for an additional premium amount:

            1.  Life Insurance (amount determined at time of application)

            2.  Accidental Death and Dismemberment

            3.  24 hour accident coverage (on or off the job)

            4.  Maternity

Q.  If I purchase a “group” health insurance policy, what is the lifetime maximum the insurance company will pay if I become seriously ill? 

A.   That really depends on the health plan your employer has selected for your “group.”  Most “group” health insurance plans have a set, lifetime maximum amount that they will pay if you become seriously ill. 
In most cases, this lifetime maximum amount is $1 million, $2 million, $5 million.  HMO’s usually offer an unlimited lifetime maximum.  Note:  Many plans now impose a “per illness” cap, usually $1 million dollar per illness.
If an illness exceeds $1 million coverage for that illness is exhausted, regardless of the total lifetime maximum amount of the policy.  Consult your Benefits Administrator or Insurance Agent for more information about
“per illness” caps, before you decide on a policy.

Q.   Is maternity coverage automatically included on a “group” health insurance policy?

A.   No.  Most “group” major medical plans offer normal pregnancy benefits as an optional coverage. Coverage for complications of pregnancy is a required benefit for all major medical health insurance plans currently
issued in Illinois. 

Q.  If I have a “group” health plan doesn’t include “maternity” coverage, how can I possibly afford to pay for my pregnancy and delivery on my own? 

A.   Many hospitals and OB/GYNs offer affordable pre-payment plans for pregnancies and deliveries.  Some plans will allow you to pay a set monthly amount during your pregnancy and a larger fee right before your
delivery date.  These fees customarily will cover all prenatal care and a normal vaginal delivery.  However, some medical services, such as pre-natal ultrasounds, amniocentesis and genetic testing may not be included. 
These medical services, will, most likely, have to be paid out-of-pocket.  If you don’t have a health insurance plan that provides coverage for “maternity” you should speak to your doctor as soon as you discover that
you are pregnant. You and your doctor can determine what care you will need and what costs involved. If you are a low income expectant mother without “maternity” coverage, you may qualify for the State of Illinois
FAMILYCARE program (formerly KIDCARE). FAMILYCARE insures expectant mothers who meet income requirements. For information call the FAMILYCARE hotline toll-free at 866 ALL KIDS (255 5437)
or you can find them on the web @ www.familycareillinois.com

Q.   If I don’t have “group” health insurance coverage during my pregnancy, can I immediately insure myself and my infant as soon as s/he is born?

A.  No.  If you are not currently participating in your employer’s “group” health insurance plan and you become pregnant, you will have to wait until the next open enrollment period to apply for “group” health insurance
coverage. If you sign up for “group” coverage prior to giving birth, your infant will automatically be covered as soon as s/he is born. Insurance companies usually require that you contact them within 31 days from the date
of delivery to add your child on to your policy as a dependant. Contact your company’s Benefits Administrator or Insurance Agent if you have any questions regarding your “group” health insurance insurance benefits.

Q.  Can I participate in my employer’s “group” health insurance plan that provides “maternity” coverage if I am already “pregnant?” 

A.   Yes. You can enroll in your employer’s “group” health insurance plan as soon as you become eligible. If you are a new employee, you are usually eligible for “group” health insurance in 30, 60 or 90 days. If you are
a current employee and you are already participating in your employer’s “group” health insurance plan, you will be automatically covered for any expenses related to your pregnancy.

Q.   If I have a “group” health insurance policy that doesn’t have “maternity” coverage and I give birth, is my infant automatically covered as soon as s/he is born? 

A.   Yes. You have 31 day window from the time your infant is born to add your child on to your “group” health insurance policy as a dependant.  If you do not add your new baby on to your  plan health insurance within
the 31 day window you may have to wait to the next open enrollment period to add your child onto your policy.

Q.  If I have a “group” health insurance policy that does not include “maternity” coverage and I have to have an emergency C-section, will my C-section surgery be covered by my health insurance  plan? 

A.  Yes, an emergency C-section is considered a “complication of pregnancy” and is normally covered under most health insurance plans, even if you have not added “maternity” coverage to your policy.

Q.   If I am on a “group” health insurance plan and do not need “maternity” coverage, can I decline that benefit to decrease my monthly insurance premium?

A.   No. You can not decline “maternity” coverage to lower your monthly insurance premium, even if you do not need “maternity” coverage.

Q.  If I purchase a “group” health insurance plan for my employees, are MY rates affected by the health conditions of my employees?

A.  Yes. The rates of your “group” are primarily determined by the age of the individuals in the “group” and the health status of those individuals. If there are several individuals in the “group” with serious medical conditions,
the rates for every individual in the “group” will be much higher than if everyone in the “group” was perfectly healthy. The purpose of “group” health insurance is to share the risk between several individuals, some healthy,
some sick. Unfortunately, if you have a “group” with