RESOURCES

Frequently Asked Questions

Roger Hicks and Associates prides itself with knowledgeable individuals that assist clients everyday with questions and answers as they relate to health insurance and other questions that relate to group and individual benefits. We are always here to assist both our clients and prospective clients with any insurance needs they may have. If you have a question, please e-mail us at info@callhicks.com for a response from a team of dedicated individuals.

How do I order another insurance card?
If you are a current client, simply e-mail us with your name, current address, social security number, date of birth, and the name of company you work for at info@callhicks.com and we will do the rest for you! Or you can go online if you carry BCBS, United, Pacificare or Principal.

I am an employer and I have all older employees, do I have to offer maternity coverage?
 Yes, if you are an employer with 15 or more employees. Under the Pregnancy Discrimination Act, an amendment to Title VII, employers who are required to comply with Title VII must offer maternity benefits http://www.eeoc.gov/facts/fs-preg.html.

I want to drop my health insurance coverage, can I do this at any time?
 Depending on your company’s policy (they may require additional documentation supporting the request) or if you are participating in the employer’s Section 125 Plan (a/k/a Cafeteria Plan), then you may drop coverage and discontinue your 125 pre-tax premium by having a ‘qualifying event’. However, if you are NOT participating in a Section 125, you may drop your coverage at any time. Be aware, however, that you are not then eligible for COBRA coverage. If you want to re-enroll, you may have to wait for an Open Enrollment period or have a ‘qualifying event’.

What is a ‘qualifying event’?
 A qualifying event is defined as marriage, divorce, birth or adoption of a child, death, or loss of ‘dependent’ status of a child or involuntary loss of helath insurance coverage. Under these circumstances, you have the right to enroll or disenroll within 30 days of the event depending upon the event. For more information contact us at info@callhicks.com or go to http://www.dol.gov/ebsa/publications/life_changes.html

Can I add my spouse and/or child(ren) at any time?
 Generally, you must wait for Open Enrollment to make changes to your group health insurance elections. However, HIPAA contains provisions for Special Enrollment opportunities if you have a qualifying event as described above. Contact your employer immediately or contact us at info@callhicks.com if you have questions or concerns.

I am quitting my job, am I eligible for COBRA?
 If your employer has 20 or more employees within the last calendar year, then it is probable that your employer must give you a COBRA election notice. The notice will provide you with your election time frame (60 days from your date of termination or loss of coverage date, whichever is later) and the amount of the premium you are required to remit within 45 days of the date you elect COBRA continuation coverage. You may only elect COBRA continuation coverage if you were covered on the health plan the day before you terminated your employment. The same is true of any dependents. You may not request to add dependents if they were not previously covered on the group health plan the day before the covered person lost coverage.

What is a pre-existing condition?
 A preexisting condition is a medical condition present before your enrollment date in any new group health plan. Under HIPAA, the only preexisting conditions that may be excluded under a preexisting condition exclusion are those for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period before your enrollment date. (Your enrollment date is your first day of coverage, or if there is a waiting period to get into the plan, the first day of the waiting period.)

If you had a medical condition in the past, but have not received any medical advice, diagnosis, care or treatment within the 6 months prior to your enrollment date in the plan, your old condition is not a preexisting condition to which an exclusion can be applied. Moreover, under HIPAA, preexisting condition exclusions cannot be applied to pregnancy, regardless of whether the woman had previous health coverage.

In addition, a preexisting condition exclusion cannot be applied to a newborn, adopted child under age 18, or a child under age 18 placed for adoption as long as the child became covered under health coverage within 30 days of the birth, adoption or placement for adoption and provided that the child does not incur a subsequent 63-day break in coverage.

Finally, genetic information may not be treated as a preexisting condition in the absence of a diagnosis. If your coverage is through an insurance company or offered through an HMO, state law may provide additional protections.

How do I know the length of my preexisting condition exclusion period?
 The maximum length of a preexisting condition exclusion period is 12 months after your enrollment date (18 months in the case of a late enrollee). A late enrollee is an individual who enrolls in a plan other than on the earliest date on which coverage can become effective under the terms of the plan and other than on a special enrollment date.

A plan must reduce an individual’s preexisting condition exclusion period by the number of days of an individual’s creditable coverage. However, a plan is not required to take into account any days of creditable coverage that precede a break in coverage of 63 days or more (significant break in coverage).

A plan generally receives information about an individual’s creditable coverage from a certificate furnished by a prior plan or health insurance issuer (e.g., an insurance company or HMO). A certificate of creditable coverage must be provided automatically to you by the plan or issuer when you lose coverage under the plan or become entitled to elect COBRA continuation coverage and when your COBRA continuation coverage ceases. You also have a right to receive a certificate when you request one from your previous plan or issuer within 24 months of when your coverage ceases.

What does ‘deductible’ mean?
 Your deductible is determined by the plan your employer selects. The deductible is the amount that you pay for services before the insurance company pays the coinsurance. For example, if you have a $1,000 deductible and you have outpatient surgery conducted. The allowable amount (that is, the amount that the provider and the insurance company have negotiated) is $4,000. You will pay the first $1,000 (your deductible) leaving $3,000. The insurance company will then pay their portion of the coinsurance (90%, 80%, 70%, 60%, 50%, etc.). In this instance, let’s assume the coinsurance is 80%, so the insurance company will pay 80% of the $3,000 which equals $2,400. You will pay the 20% coinsurance (80% + 20% = 100%) which equals $600.

In this case you will pay $1,600 toward the $4,000 procedure and the insurance company would have paid $2,400.

What is ‘coinsurance’?
 Coinsurance is the percentage that is split between the insurance company and the individual after the deductible has been met. If you are staying within your network of providers, it ranges from 90%/10%, 80%/20%, 70%/30%, 60%/40%, and so on. The insurance company pays the first percentage amount and the individual is responsible for the remaining percentage. Both percentages together equal 100%.

How can I find insurance information for Spanish-speaking employers and employees?

The National Association of Insurance Commissioners recently launched a new Spanish-language Web site that employers and employees can use to help educate Spanish-speaking consumers on various types of insurance.

Commonly Used Acronyms.

ADA- Americans with Disabilities ActADEA- Age Discrimination in Employment Act
ASO- Administrative Services Only (usually applies to Self-Insured groups)CDHC- Consumer Driven Health Care
CFR- Code of Federal RegulationsCMS- Centers for Medicare and Medicaid Services
COBRA- Consolidated Omnibus Budget Reconciliation ActCOC- Certificate of (Creditable) Coverage
DOL- Department of LaborDOMA- Defense of Marriage Act
DCAP- Dependent Care Assistance ProgramDCTC- Dependent Care Tax Credit
EAP- Employee Assistance ProgramEBSA- Employee Benefits Security Administration
EEOC- Equal Employment Opportunity CommissionEGTRRA- Economic Growth and Tax Relief Reconciliation Act
EOB- Explanation of BenefitsEOI- Evidence of Insurability
ERISA- Employee Retirement Income Security ActFICA- Federal Insurance Contributions Act
FLSA- Fair Labor Standards ActFMLA- Family Medical Leave Act
FSA- Flexible Spending Account (a.k.a Section 125 Cafeteria Plan)FUTA- Federal Unemployment Tax Act
GTL- Group Term Life InsuranceHCE- Highly Compensated Employee
HDHC- High Deductible Health CoverageHDHP- High Deductible Health Plan
Health FSA- Health Flexible Spending AccountHHS- Department of Health and Human Services
HIPAA- Health Insurance Portability and Accountability ActHMO- Health Maintenance Organization
HRA- Health Reimbursement ArrangementHSA- Health Savings Account
LTD Plan- Long Term Disability PlanMEWA- Multiple Employer Welfare Arrangement
MHPA- Mental Health Parity ActMSA- Medical Savings Account
MSP- Medicare Secondary PayerNAIC- National Association of Insurance Commissioners
NMHPA- Newborns' and Mothers' Health Protection ActNon-HCE- Non-Highly Compensated Employee
OHCA- Organized Health Care ArrangementOTC- Over the Counter Drug
PCE- Pre-existing Condition ExclusionPDA- Pregnancy Discrimination Act
PEO- Professional Employer OrganizationPHI- Protected Health Information
POP- Premium Only PayPPO- Preferred Provider Organization
PWBA- Pension and Welfare Benefits Administration (now known as Employee Benefits Security Administration; EBSA)QDRAO- Qualified Domestic Relations Order
QMCSO- Qualified Medical Child Support OrderSAR- Summary Annual Report
SMM- Summary of Material ModificationsSPD- Summary Plan Description
TPA- Third Party AdministratorUSERRA- Uniformed Services Employment and Reemployment Rights Act
WHCRA- Women's Health and Cancer Rights Act
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