Health Insurance

What is a Health Insurance?

It's a fact of life — you need health insurance — and the time to get it is before you have an accident, suffer a serious illness, or discover you're pregnant. Insurance doesn't cover health care for medical problems or conditions that start before the moment you have your policy. Finding adequate coverage may seem overwhelming, but knowing the basics can help make your search less stressful.

The Basics of Short-Term Health Insurance

Whether you're graduating from college, leaving home for the first time, or between jobs, a major change in your lifestyle often dictates a change in your health insurance coverage. For these circumstances, some health insurers offer short-term or temporary health plans (sometimes called "major medical" plans) to fill in the gaps between traditional policies.
With low premiums and high deductibles, short-term policies are designed to be more of a low-cost safety net in case of serious injury or illness than a comprehensive day-to-day health insurance plan. Benefits are limited and there are strict eligibility requirements to qualify. Additionally, temporary health insurance is just as the name implies, only a temporary solution. While some plans offer coverage for up to a year, most short-term policies offer between one month and six months of coverage.

Who needs short-term health insurance?

Despite its limitations, short-term health insurance serves an important function for certain groups of people:

• Recent college graduates are among the most likely consumers of short-term health insurance, according to insurers such as GradMed that specifically target graduating students who will lose their health insurance when they leave school. Many grads will look for jobs that will offer health insurance benefits, but until they find that job, short-term insurance can fill the gap. (For recent grads looking for more permanent coverage, many college alumni associations offer some sort of group health policy to their members.
• Short-term plans may also be attractive to individuals who are temporarily out of work. Many people who are laid off or are between jobs can continue coverage with their previous employer under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) for up to 18 months, until a new employer's plan kicks in. However, some people may find that COBRA premiums are too high for their budget. A short-term policy with lower premiums may be the solution.
  
  If your previous employer is a small business with less than 20 employees, you may not be covered under COBRA. Also, if your previous employer goes out of business, you will not be covered by COBRA because the insurance pool to which you once belonged will be dissolved. In these instances, a short-term policy may be your best option until you can find coverage elsewhere.
  
  
• Those losing dependent status under their parents' health coverage are also likely consumers of short-term coverage. If you reach age 18 and are not enrolled as a full-time student, you will most likely be dropped from your parents' health insurance policy. In this situation, you will be eligible for COBRA, but premiums can be very high. A short-term policy can keep you insured for less until you find a job that offers health insurance, or you enroll in an individual health plan.
• Finally, you might consider a short-term plan if you are temporarily without insurance for some other reason. Maybe you are out of work on strike, recently discharged from the military, or have retired early and need coverage until you qualify for Medicare.

How does it work?

One advantage to a short-term health insurance plan is that it works like an "indemnity" plan in the sense that you have no preferred care provider (PCP) or gatekeeper, and you are not confined to an HMO network of doctors. Short-term plans give you the freedom to go to any doctor or specialist you like.
The kind of treatments covered by a short-term policy are fairly comprehensive. Surgery, hospital care, emergency services, diagnostic tests, prescription drugs, follow-up office visits, and even limited mental health care are included under short-term coverage.

There are, however, several areas where short-term coverage falls short of a traditional policy:

• Preventative care, including physical exams, immunizations, and PAP tests, as well as child-wellness care, are not covered, except where required by state law.
• Like most individual health insurance policies, short-term coverage excludes pre-existing conditions. The "look-back" period for these conditions varies by state, but the most common rule for short-term policies is that providers may exclude coverage for conditions diagnosed or treated within the last five years. Because temporary policies are so short, the exclusion of pre-existing conditions will last the life of the policy.
• Maternity care is almost never covered by short-term insurance. Most plans will cover complications arising from pregnancy, but routine doctors' visits are excluded.
• Most short-term policies are nonrenewable. If you decide that you want to extend your short-term policy, your provider will make you apply for a new policy.
  Most insurers will let you reapply only once, and the two policies together cannot exceed the maximum length of coverage issued by your insurer. For instance, if your insurer issues short-term policies for a maximum of six months, and your first policy was for four months, your second policy will only be good for a maximum of two months.
  Some insurers will flatly refuse to issue you a second policy if you filed any claims under your previous short-term policy. Others might offer you another policy, but they will treat any injuries or illnesses that occurred during your previous short-term policy as pre-existing conditions and thus will not cover treatment related to such conditions.

What will it cost me?

One of the major appeals of a short-term policy is its low premiums. A typical plan can cost as little as $30 a month for a single male in his early 20s, according to quotes provided by Fortis Health (premiums vary significantly according to factors such as your age and where you live).
The flip side of paying such a low premium is the high deductible that accompanies this type of policy. While traditional policies require you to make co-payments for medical care as low as $5, short-term deductibles start at $250 and range into the thousands.
To illustrate the point, consider the single male in his early 20s who is paying only $30 a month for short-term coverage. The reason his premium is so low is that the deductible is a whopping $2,500.
Another thing to keep in mind is that with some short-term policies you must pay a deductible per injury or illness. That means that the deductible must be met each time you are treated for a new condition. With the high deductibles required by short-term providers, the money you pay out of pocket can really add up.
Even after you've met your deductible, most insurers won't pay the total remaining bill. Most plans let you choose one of two payment plans. Under the first plan, the insurer will pay 80 percent of the first $5,000 (this amount may vary among policies), and 20 percent of the costs thereafter. The second plan requires the insurer pay 50 percent of all costs after the deductible is met, up to the maximum benefit (usually $1 million or $2 million).
Many plans will also allow you to choose whether you want to pay a lump sum for a designated period of coverage or you want to pay your premiums on a monthly basis. The advantage of the monthly payment option is that it allows you to continue coverage for an unspecified number of months (but not more than a year). You will pay more for this flexibility, however.

Who's eligible?

In the end, if you still think that a short-term health insurance policy is right for you, there's a good chance that you won't qualify to get one.
Short-term policies with low premiums and high deductibles are designed to be a safety net and insurers don't want to provide safety-net policies with low premiums to people who are likely to need them.
Consequently, most insurers require that you are at least two weeks old and that your age will not advance past 65 during the life of the policy. If you have ever been denied health insurance before, you won't be eligible for short-term insurance, because a previous denial indicates you might have significant health problems.
In addition, you won't be eligible if: you are covered by another health insurance plan already, you work in a hazardous industry such as construction or aviation, or you play in collegiate or professional sports.
While no short-term health insurance provider will cover routine maternity care, some providers won't even issue a policy to a pregnant woman.
Many people may find short-term health insurance coverage appealing because of its relatively low price tag. However, it is important to remember that like any other product or service, you get what you pay for.

The Basics of Long Term Care Insurance

The harsh realities of aging in America are coming into sharp focus. Soon, a 95-year-old baby boomer without long term care insurance may have to rely on a 90-year-old spouse or a 70-year-old son or daughter for personal care.
Consumers can't rely on Medicare, Medicare supplementary insurance, or health insurance to help them meet long term care costs. They don't cover most long term care expenses.

When to Buy a Long Term Care Policy

When buying long term care insurance, your age is a primary factor in determining its cost. The younger you are when you get the policy, the cheaper your premiums will be. Of course, you also will be paying those premiums for a longer period of time before taking any benefits.
A good time to buy long term care insurance is between ages 50 and 55, according to the American Health Care Association (AHCA), a federation of 50 state health organizations representing assisted living, nursing facility, long term care, and subacute care providers. A policy that costs you $800 annually when you're 55 will cost you nearly twice as much if you wait to buy it when you're 65.
There is an exception, however. You might want to purchase a long term care policy before age 50 if your employer sponsors an attractive long term care group plan at an affordable price.
Most insurers won't sell you long term care insurance if you're over 85 or if you have a pre-existing medical condition such as heart disease or diabetes. A reputable insurer only sells long term care policies to reasonably healthy people who are at low risk of needing their benefits in the foreseeable future. So beware of policies and premiums that sound too good to be true.

Important Policy Features

The most crucial factor when choosing a long term care policy should be its benefit triggers, the set of conditions that must exist before you begin receiving coverage. Ordinarily, you must have an acute medical condition that requires skilled nursing care before your benefits kick in. The best, and most expensive, policies allow you to start receiving benefits if you suffer from a cognitive impairment such as Alzheimer's disease, even if you can bathe and dress yourself.
Bathing is one of several activities of daily living, or ADLs, which are the most commonly used benefit triggers. Your benefits begin when you are no longer able to perform a certain number of ADLs without assistance. (Your policy will determine that number. A good LTC policy will require the inability to perform two ADLs.)

A good long term care policy also will cover all levels of care — including custodial or personal care — in a variety of settings. Those settings include:

• Adult day care: Sites that provide personal and skilled care, and recreational services.
• Assisted living facilities: Living quarters that provide individualized personal care and health services for people who need help with personal care.
• Facility care services: Licensed agencies that provide skilled nursing care, speech, physical, or occupational therapy, or help from health aides.
• Nursing facilities: Residential sites for people who need daily medical care. Many nursing home stays are for a short rehabilitative period after an acute illness or injury such as a hip fracture.

Make sure you know exactly what types of services and facilities are covered by your long term care policy. If you don't go to the right kind of facility, your insurance company can refuse to pay for your care.
You also should investigate whether your policy has a nonforfeiture benefit, which is additional long term care coverage you can buy that protects some of your policy's value if you drop your policy or let it lapse. While this benefit offers some protection for your investment, it will raise your premiums. If you are confident you will be able to pay your premiums, even if there are future rate hikes, you can lower your costs by passing up this option. See Insure.com's "Choosing among long term care insurance riders".
Waiver of premium is another important feature in a long term care policy. This provision lets you stop paying premiums during the time you are receiving benefits. Read your policy carefully to see whether there are any restrictions on this feature, such as a requirement to be in a nursing home for a period of time (60 to 90 days is standard) before your premiums are waived.
Most long term care policies sold today must be guaranteed renewable, which means the insurer guarantees you the chance to renew your policy. It doesn't mean the insurer guarantees you a fixed premium. Note: Your premium will probably increase over time. While you can't be singled out for a rate increase — no matter how many claims you file — you should know that state regulators routinely grant increases to insurance companies to cover whole classes of policies that experience a large number of expensive claims.