Health Insurance Brochures
The cost of health care has risen drastically over the past few decades. If you do not have medical insurance to help pay bills, a serious injury or illness can be financially devastating to you and your family. If you don’t have coverage, you can be exposed to high health care bills or, if you have too little or the wrong kind of coverage, you won’t have enough protection.
Back to the Top
- Make sure you feel confident with the insurance agent and company. It is a good idea to contact the Department of Insurance to make sure the agent and the company you are dealing with are licensed in our state.
- Learn what kinds of policies will provide what you need and pick the one best for you. Don’t hesitate to shop around and ask a lot of questions.
- Do not sign an application until you review it carefully to be sure the answers are complete and accurate. Make sure that the word "insurance" is actually used and that there is no disclaimer stating that, "This product is not insurance, nor is it intended to replace insurance."
- When you buy a policy, make the check payable to the company, not the agent. Always pay by check or money order and write your policy number on the payment. Do not give the agent your bank account number for automatic withdrawals until you have verified agent and company background information.
- Ask for a receipt for all payments. The receipt should include your policy number, the date of payment and the name of the insurance company.
Back to the Top
- The best tool for avoiding fraud is your phone. Contact the Department of Insurance to find out whether the insurance agent and company are licensed in our state.
- Fraudulent plans are most often sold through direct mail solicitations or over the internet, so be especially wary when responding to these solicitations.
- If a policy costs far less than what other companies are charging, this could be a warning sign. It’s a good thing to comparison shop, but if a policy is significantly cheaper, beware. If it sounds too good to be true, it probably is.
- Beware of an agent or company that:
- Refuses to provide proof of state licensure.
- Insists on cash payments or automatic withdrawal.
- States this is a "one-time deal" or your "last chance for special savings."
- Boasts that the coverage is available to anyone, regardless of history or
risk.
Back to the Top
Major Medical Plans
This type of policy is usually effective in covering serious illness or injury where costs are high. Hospital care, drugs and doctors’ visits are usually covered. These benefits can be delivered in several different ways:
- Indemnity plans - These major medical plans typically have a deductible – the amount you pay before the insurance company begins paying benefits. After your covered expenses exceed the deductible amount, benefits usually are paid as a percentage of actual expenses, often 80 percent. These plans usually provide the most flexibility in choosing where to receive care.
- Preferred Provider Organization (PPO) plans – In these major medical plans, the insurance company enters into contracts with selected hospitals and doctors to furnish services at a discounted rate. As a member of a PPO, you may be able to seek care from a doctor or hospital that is not a preferred provider, but you will probably have to pay a higher deductible or co-payment.
- Health Maintenance Organization (HMO) plans – These major medical plans usually make you choose a primary care physician (PCP) from a list of network providers. Your PCP is responsible for managing all of your health care. If you need care from any network provider other than your PCP, you may have to get a referral from your PCP to see that provider. You must receive care from a network provider in order to have your claim paid through the HMO. Treatment received outside the network is usually not covered, or covered at a significantly reduced level.
- Point of Service (POS) plans – These major medical plans are a hybrid of the PPO and HMO models. They are more flexible than HMOs, but do require you to select a primary care physician (PCP). Like a PPO, you can go to an out-of-network provider and pay more of the cost. However, if the PCP refers you to an out-of-network doctor, the health plan will pay the cost.
Limited Benefit Plans
These types of policies provide limited coverage for a particular health care setting, ailment or disease. Some of the options that may be available to you are:
- Basic Hospital Expense Coverage – Covers a period of usually not less than 31 days of continuous in-hospital care and certain hospital outpatient services.
- Basic Medical-Surgical Expense Coverage – Covers costs associated with a necessary surgery, including a certain number of days (usually not less than 21 days) of in-hospital care.
- Hospital Confinement Indemnity Coverage – Covers a fixed amount (usually not less than $40) for each day that you are in a hospital. The benefits paid are not based on your actual expenses.
- Accident Only Coverage – Covers death, dismemberment, disability or hospital and medical care caused by an accident. Specified accident coverage that covers only certain accidents may also be purchased.
- Specified Disease Coverage - Covers diagnosis and treatment of a specifically named disease or diseases, such as cancer.
- Other Limited Coverage – You may purchase insurance covering only dental or vision or other specified care.
Additional Coverage Options
These types of policies provide added protection should you become disabled, require long-term care, or enroll in Medicare:
- Disability Income - This coverage provides for weekly or monthly benefit payments while you are disabled after a covered injury or sickness. The disability payment is usually a set dollar amount not to exceed a certain percentage of your income. These policies usually expire when you become eligible for Medicare.
- Long-Term Care Insurance - This policy usually pays for skilled, intermediate and custodial care in a nursing home and also for care in other settings, such as the home, adult day care center or assisted living facility. The policy usually pays a fixed amount per day while a person is receiving care.
- Medicare Supplemental Coverage - The federal Medicare program pays most medical expenses for people 65 or older, or for individuals under 65 receiving Social Security disability benefits. However, Medicare does not pay all expenses. As a result, you may want to buy a Medicare Supplement policy that helps pay for certain expenses, including deductibles not covered by Medicare.
These are NOT health insurance plans:
- Discount Plans
You may receive advertisements from plans offering discounts on health care for a monthly fee. These are not health insurance plans and participants do not have the same protections as under licensed health insurance plans. The Department of Insurance strongly recommends that you thoroughly investigate any plan promising deep discounts for a “low” monthly fee and weigh the benefits against the cost carefully.
- Non-Licensed Risk-Sharing Plans
You may receive offers to join a group or association that will take your monthly payments, put them in a savings account (or trust) with other participants’ money, and then help pay some of your health care costs, as needed. Such arrangements are not insurance and the participants do not have the protections available to purchasers of licensed insurance plans. The Department of Insurance strongly recommends that you thoroughly investigate such plans before joining.
Back to the Top
- Cancer Insurance is Not a Substitute for Comprehensive Coverage
Cancer treatment only accounts for a small percentage of the American public’s health care bill. That is why it is essential to have insurance coverage for all conditions, not just cancer.
- Consider a Major Medical Policy if Your Family is Not Protected
If you and your family are not protected against catastrophic medical costs, consider a major medical policy. These policies pay a large percentage of your covered costs after a deductible is paid.
- You May Not Need Extra Coverage
Ask yourself these three questions: Is my current coverage adequate for these costs? How much will the treatment cost if I do get cancer? How likely am I to contract the disease?
- Duplicate Coverage is Expensive and Unnecessary
Buy basic coverage first and then make sure a cancer policy will meet any needs not covered by your primary plan. Don’t assume that double coverage will result in double benefits.
- Some Expenses May Not be Covered by This Policy
Cancer patients often face large, non-medical expenses that are not usually covered by cancer insurance. Examples are home care, transportation and rehabilitation costs.
- The Odds are Against Your Developing Cancer
While 3 in 10 Americans will get cancer over a lifetime, 7 in 10 will not.
- Check the Policy’s Limitations
Some policies pay only for in hospital care. Many treatments, including radiation, chemotherapy and some surgeries, are often given on an outpatient basis.
- No Policy Will Cover Cancer Diagnosed Prior to Policy Application
Some policies will deny coverage if you are later found to have had cancer at the time of purchase, even if you did not know it.
- Most Cancer Insurance Does Not Cover Cancer-Related Illnesses
Cancer or its treatment may lead to other physical problems, such as infection, diabetes or pneumonia.
- Many Policies Contain Time Limits
Some policies require waiting periods of 30 days or even several months before you are covered. Others stop paying benefits after a fixed period of two or three years.
Back to the Top
If you purchased insurance coverage from a licensed insurer, you have the benefit of many important protections.
COBRA Continuation Coverage
If you purchase insurance coverage through your employer and your employer has 20 or more employees, you are entitled to continuation coverage by the federal Consolidated Omnibus Budget Reconciliation Act (COBRA).
Our state has a mandatory continuation of coverage privilege. The law provides that an employee or member who has been insured under the group policy for at least six months and who loses coverage for any reason (other than nonpayment of premium) may continue coverage for the fractional policy month remaining plus six months.
Under COBRA, if you leave your current job, you have the option to continue your health care coverage for up to 18 months. You are required to pay the full premium yourself, even if your employer paid part of your premium while you were employed, and the employer may charge an additional, limited administrative fee. You can find out more about COBRA continuation of group health benefits from the Federal Department of Labor Office of Employee Benefits Security Administration site.
To be an "eligible individual," you must meet all of the following criteria:
- You must have had 18 months of continuous creditable coverage, with at least the last day having been under a group health policy (coverage is considered continuous if it is not interrupted by a break of 63 or more consecutive days).
- You must have used up any COBRA group continuation coverage for which you were eligible. See the above section for information on COBRA.
- You must not be eligible for Medicare, Medicaid or a group health policy.
- You must not have other major medical health insurance.
- You must apply for health insurance for which you are deemed an “eligible individual” within 63 days of losing your prior coverage.
HIPAA
HIPAA is the Health Insurance Portability and Accountability Act of 1996. It limits insurers' powers to deny or delay claims, reduces your chances of losing existing coverage, makes it easier and less risky to switch health plans, and prohibits insurance discrimination based on health problems.
Key HIPAA Protections
- Non-Discrimination
In a group plan, the insurer may not apply different eligibility rules, offer different benefits, or charge a higher premium to any individual on the basis of certain “health factors” – health status, claims experience, medical history or genetic information.
- Guaranteed Issue
Insurers providing small group coverage must offer coverage to any small employer that applies, regardless of health status or prior claims experience of the employees.
- Guaranteed Renewability
Insurers may not cancel a health plan unless the beneficiary fails to pay the premiums or the insurer stops doing business in the market.
- Limits on Pre-Existing Condition Exclusions
Insurers may not exclude (refuse to cover) treatments and services related to medical conditions that existed before the beneficiary purchased the health plan for a period more than 12 months. If the person has had continuous coverage prior to purchasing the new plan, there can be no coverage exclusions.
The SC Department of Insurance is ready to help you with any question or complaint you may have about your coverage. Please do not hesitate to contact the Office of Consumer Services at any time!
Back to the Top
What Types of Plans will Help Cover Seniors' Health Costs?
Long Term Care Insurance
Medicare Supplement Insurance
Back to the Top
These are individual insurance policies that may help you when you are unable to take care of yourself due to prolonged illness or disability. These policies usually pay for skilled, intermediate and custodial care in a nursing home. Home health care, adult day care, and assisted living care are also often covered. These policies usually pay a fixed amount per day or per visit to facilities or caregivers that are licensed by the state and/or participate in Medicaid and Medicare.
Back to Seniors' Health Plans
Benefits paid by a tax-qualified long term care plan generally are not taxable as income. Benefits from a non-tax-qualified long term care plan may be taxable as income. Check with your tax advisor about the possibility of deducting a portion of the premiums paid in addition to the individual tax consequences involved.
Back to Seniors' Health Plans
Not really. Medicare will pay for some home health care and skilled nursing facility care following a hospital stay – as continuing care. It does not pay for nursing home care or longer-term home care.
Back to Seniors' Health Plans
Yes, but you must meet very low-income and asset requirements to qualify for Medicaid. Contact the Department of Insurance for more information.
Back to Seniors' Health Plans
- Long Term Care is Different From Traditional Medical Care
Someone with a prolonged physical illness, a disability or a cognitive impairment, such as Alzheimer’s disease, often needs long term care. Long term care services may include help with daily activities, home health care, respite care, hospice care, adult day care, care in a nursing home or care in an assisted living facility.
- Long Term Care Can be Expensive
The cost depends on the amount and type of care you need and where you get it. In 2001, the national average cost of nursing home care was $56,000 per year, assisted living facilities reported $22,476 per year and home care costs ranged from $12,000 to $16,000 per year.
- You Have Options When Paying for Long Term Care
People pay for long term care in a variety of ways. These include using personal resources, long term care insurance and Medicaid for those who qualify. Medicare, Medicare supplement insurance and health insurance you may have at work usually will not pay for long term care. Long term care insurance will pay for some or all of your long-term care.
- Decide Whether Long Term Care Insurance is for You
Whether you should buy a long term care insurance policy will depend on your age, health status overall retirement goals, income and assets. For instance, if your only source of income is a Social Security benefit or Supplemental Security Income (SSI), you probably should not buy long term care insurance since you may not be able to afford the premium. On the other hand, if you have a large amount of assets but do not want to use them to pay for long-term care, you may want to buy a long term care insurance policy. Many people buy a policy because they want to stay independent of government aid or the help of family. They don’t want to burden anyone with having to care for them. However, you should not buy a policy if you can’t afford the premium or are not sure you can pay the premium for the rest of your life.
- Pre-Existing Condition Limitations
A long term care insurance policy usually defines a pre-existing condition as one for which you received medical advice or treatment or had symptoms within a certain period before you applied for the policy. Some companies look further back in time than others. Many companies will sell a policy to someone with a pre-existing condition. However, the company may not pay benefits for long term care related to that condition for a period after the policy goes into effect, usually six months. Some companies have longer pre-existing condition periods or none at all.
- Know Where to Look for Long Term Care Insurance
Long term care insurance is available to you in several different forms. You can buy an individual policy from a private insurance company or agent or you can buy coverage under a group policy through an employer or association membership. The federal government and several state governments offer long-term care insurance coverage to their employees, retirees and their families. You can also get long-term care benefits through a life insurance policy. Some states have long-term care insurance programs designed to help people with the financial impact of spending down to meet Medicaid eligibility standards. Check with the Department of Insurance to see if these policies are available in our state.
- Check With Several Companies and Agents
Contact several companies and agents before you buy a long-term care policy. Be sure to compare benefits, the types of facilities covered, limits on your coverage, what is not covered and the premium. Policies from different insurance companies often have the same coverage and benefits but may not cost the same. Be sure to ask companies about their rate increase history and whether they have increased the rates on the long-term care insurance policies.
- Don’t be Misled by Advertising
Most celebrity endorsers are professional actors who are paid to advertise, not insurance experts. It is also important to note that Medicare does not endorse or sell long-term care insurance policies, so be wary of advertising that suggests Medicare is involved. Do not trust cards you get in the mail that look like official government documents until you check with the government agency identified on the card.
- Make Sure the Insurance Company is Reputable
To help you find out if an insurance company is reliable, you can take the following actions: Stop before you sign anything, contact the Department of Insurance and confirm that the insurance company is licensed to do business in our state. After you make sure they are licensed, check the financial stability of the company by checking their ratings. You can get ratings from some insurer rating services for free at most public libraries.
- Review Your Contract Carefully
When you purchase long term care insurance, your company should send you a policy. You should read the policy and make certain you understand its contents. If you have questions about your insurance policy, contact your insurance agent for clarification. If you still have questions, contact the Department of Insurance.
Back to Seniors' Health Plans
Medicare Supplement Insurance
The federal Medicare program pays most medical expenses for people 65 or older or for individuals under 65 receiving Social Security disability benefits. However, Medicare does not pay all expenses. As a result, you may want to buy a Medicare Supplement policy that helps pay for certain expenses, including deductibles not covered by Medicare.
Back to Seniors' Health Plans
When you elect coverage under Medicare Part B either due to age or disability, you have a 6-month open enrollment for a Medicare supplement policy, which guarantees you coverage with a plan and company of your choice. You may choose from a list of standardized plans – listed as A through L. If you do not purchase a plan within your 6-month open enrollment, any company you apply to can deny coverage based on your health conditions. There are some limited additional open enrollment periods available to some persons disenrolling from a Medicare HMO.
Back to Seniors' Health Plans
Medicare supplement policies may not include prescription drug coverage. Those who currently have a policy with prescription drug coverage may opt to keep that coverage or switch to the new Medicare prescription drug plans.
Back to Seniors' Health Plans
MedicareAdvantage plans (formerly known as Medicare+Choice plans) are private managed care plans that provide the standard Medicare benefits, plus additional supplemental benefits for a monthly fee. These plans may include prescription drug coverage. MedicareAdvantage participants may even receive a subsidy for their prescription drug benefits in most cases.
Back to Seniors' Health Plans
Medicare Select plans provide supplemental benefits through a network of providers similar to a Preferred Provider Organization (PPO). If the participant received care for a provider under contract with the insurer, the cost will be lower.
Back to Seniors' Health Plans
- Know Why You Might Need a Medigap Policy
A Medigap policy is health insurance sold by private insurance companies to fill the “gaps” in an original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the original Medicare Plan does not cover. If you are in the original Medicare Plan and have a Medigap policy, then Medicare and your Medigap policy will each pay their share of covered health care costs.
- Some Examples of “Gaps” in Medicare
You may want to buy a Medigap policy because Medicare does not pay for all of your health care. There are “gaps” or “out-of-pocket” costs that you must pay in the original Medicare Plan. Some examples of costs not covered are hospital stays, skilled nursing facility stays, blood, Medicare Part B yearly deductible and Medicare Part B covered services.
- Some Examples of Care Not Covered by Medigap
Long-term care, vision or dental care, hearing aids and private-duty nursing are things that a Medigap policy will not cover.
- Eligibility Requirements
To buy a Medigap policy, you generally must have Medicare Part A and Part B. You are guaranteed the right to buy a Medigap policy if you are in your Medigap open enrollment period or covered under a Medigap protection. You might not be able to buy a Medigap policy if you are in a Medicare Advantage Plan, have Medicaid, already have a Medigap policy or are under the age of 65 and you are disabled or have End-Stage Renal Disease.
- Pre-Existing Conditions
A pre-existing condition is a health problem you had before the date a new insurance policy starts. In some cases, if you have a health problem before your Medigap policy started, a Medigap insurance company can refuse to cover that health problem for up to six months. This is called a "pre-existing condition waiting period." The insurance company can only use this kind of waiting period if your health problem was diagnosed or treated during the six months before a Medigap policy started.
- In Most Cases, You Cannot Be Dropped From Medigap
If you bought your policy after 1990, the policy is guaranteed renewable. This means your insurance company can drop you only if you stop paying your premium, you are not truthful about something under the policy or the insurance company goes bankrupt. Insurance companies in some states may be able to drop you if you bought your policy before 1990. If this happens, you have the right to buy another Medigap policy.
- Shop Around for the Best Medigap Policy
Look for a Medigap policy that you can afford and that gives you the coverage you need most. As you shop for a Medigap policy, keep in mind different insurance companies may charge different amounts for exactly the same Medigap policy, and not all insurance companies offer all of the Medigap policies.
- Make Sure the Insurance Company is Reliable
To help you find out if an insurance company is reliable, you can take the following actions: Stop before you sign anything and call the Department of Insurance to confirm that the insurance company is licensed to do business in our state. You can also call the Department of Insurance for more information.
- Watch Out for Illegal Insurance Practices
You should know it is illegal for anyone to pressure you into buying a Medigap policy, lie or mislead you to switch to another company or sell you a second Medigap policy when they know that you already have one. It is also illegal to sell you a policy that cannot be sold in our state.
- Understand Your Medigap Rights and Protections
You need to know that under Federal law, you have rights and protections regarding your Medigap coverage. These include your right to buy Medigap coverage, protections if you lose or drop your health care and protections for people with Medicare under the age of 65. Contact the Department of Insurance to better understand these rights and protections.
Back to Seniors' Health Plans
Print and complete the Consumer Complaint form below and return to the Department of Insurance.
Consumer Complaint Form [pdf 26k]