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Las Vegas Health Insurance Expert
Telephone: 1-702-430-9767
Toll Free: 1-888-268-4421
E-mail: info@las-vegas-health-insurance-expert.com

Health Insurance Info:

Las Vegas Health Insurance Expert:

How Insurance Works

Updated Wednesday, August 4, 2010 2:45 PM

Health Insurance pays for expenses incurred for the diagnosis and treatment of covered medical conditions. There are many different types of health insurance plans available in Nevada. There is Group (Employer sponsored plans) and Individual health insurance plans. Group is great, you get the employer helping you out on the monthly payment, it has low deductibles and co-pays, and no matter what is going on with you medically, you are accepted. Usually the plans are HMO, PPO or POS.

Las Vegas Individual Health Insurance is a whole new ballpark. You know the big companies out there, Aetna, Humana, Blue Cross Blue Shield, HealthNet, Cigna, Celtic, Sierra Health, United Health Care, Assurant..... They are the major medical companies that will assess if you are a liability or not. This means you may or may not get a policy with them. For example, if you have Type I diabetes, they won't give you an insurance policy. If you had a heart attack recently or TIA, again, they will not give you a policy, they deem you as a high risk person and the probability of you having more medical issues in the future is high, so why would they take you? Think about it, if you had an insurance company and you got only $100 a year in premiums and your clients were using $1000 a year in medical services, would you be in business long? Not at all, so the insurance companies are there to protect relatively healthy people that have something happen to them. Now, no one is 100% healthy, we have all had little issues like a broken bone, an ingrown toenail, or perhaps even an appendix taken out. So, how do people get insurance? Major illnesses or accidents can be deniable, but things that are recoverable are usually no big deal to the insurance company. However, they may increase your premium to make it "worth it" to cover you with health insurance. If you are prone to accidents, say you have a high risk lifestyle (like you ride a motorcycle), they will rate up the premium when you apply if they accept you, even if you have never been in an accident. It's all about statistics. If you are overweight, they may rate you up or deny you insurance, depending on how overweight you are, because studies show that obesity is a major contributor to major diseases. This is what the Health Care Reform bill is trying to get rid of. These major medical, bare bones plans will cover you after you meet the out of pocket maximum. They are usually HMO's and PPO's. Very rare to find POS in individual health insurance.

What Health Insurance Plans Are In Nevada:

The Department of Insurance for each state determines who and what can be sold in that particular state. In Nevada, you have a lot of companies, but only a few are competitive, or have big networks, or have great contracted rates. Some of the companies have better premiums for what you get than the others. And it changes all the time, so this is where an Independent Broker from Las Vegas Health Insurance Expert comes in. An Independent Broker from L.V.H.I.E. is free of charge and using one will not change your premium whatsoever, but they get credit for you buying your policy through them. An Independent broker is "appointed" or rather; able to sell policies from one or more health insurance companies. They listen to your needs and what your comfort zones are, then go out and find matching policies for your needs and your price range, bring them back to the table and describe for you how each one works. This is important, because I bet you still didn't know how your last health insurance policy worked in detail, all you knew is what your deductible was, if you had one, and how much it cost to go to the doctor, right? Few experience critical illnesses to experience meeting their deductible and going into co-insurance, etc, etc...and learning the details of their policy (and at the worst time, after they had bought the insurance policy and they had a critical illness!). A good broker will explain what your total liability or "exposure" is, the difference of the "In Network" and "Out of Network" deductibles, and it's very important that we will be there after the sale to help you with maximizing your insurance value! We provide services long after you have bought the policy, we are like health insurance concierges our goal is to be that one phone you make to take care of questions, discrepancies or to check your claims to see that you are not over paying. With so many brokers out there, you can be choosy and you should go with the broker that educates you, that you trust, and who gives it to you straight. And, of course, saves you money by presenting you with the best VALUE for you regarding all of the policies that are out there and someone who is there for you.

Remeber Health Insurance Prices are FIXED by law, you wont find a better price for the same product. OUTSTANDING CUSTOMER SERVICE AND OUR PASSION TO EDUCATE before and after you get your health insurance policy. It's what sets us apart!

Nevada Health Doctor and Nurse

Why Do You Buy Insurance (and for that matter, use a broker to buy your insurance): For the "What If" that happens, of course! You know this, that is why you are looking into buying insurance. But the main question is "what can I get and can I afford it?" All insurance will cover the catastrophic, but what about preventative or once in a while stuff? There are two kinds of policies out there; non co-pay plans, and co-pay plans. Non Co-pay Plans: Typically when you don't have a co-pay plan, it's just bare bones insurance solely for the "What if" emergency scenario. These plans don't give you anything until the deductible is met, they can occur in a PPO or HSA plan. So, if you have to go to the doctor for the sniffles, you pay for it completely out of pocket. That is anywhere between $50 to $250 for a doctor's visit. This kind of plan may be all you can afford, but the most important this is you are covered if you have a critical illness or an accident. Using an "In Network" doctor will save you money on a non co-pay plan. There are two ways health insurance saves you money; contracted rate by using that "In Network" doctor, and the benefits you get that are spelled out in the policy. "In Network" means you are using the preferred doctors that the insurance company has negotiated lower prices for their services. In return, those doctors get business referred to them from the insurance company. Then the benefits spelled out in the policy give you, the client, coverage, usually up to a minimum of $1 million dollars if something happens to you.

Types Of Las Vegas Health Insurance

HMO (Health Maintenance Organization)
PPO (Prefered Provider Organization)
Indemnity (Fee For Service)
Self Insured or Single Employer
Supplemental Health Insurance
COBRA, What is COBRA?
HIPAA (Health InsurancePortability Act)
Nevada State Health Insurance Resources
Nevada Sentors & Congressional Representatives
Health Insurance Terms

HMO (Health Maintenance Organization)

First let me say many clients think that an HMO plan is less expensive. This is WRONG. An HMO plan is more expensive; a lot more money in monthly premium.

Here are the features of an HMO plan.
• Benefits are a co-pay only and usually there are no deductibles
• Premiums are higher
• The physician network is much smaller then a PPO network and you are very limited
• If you need a certain physician the odds are low that they will be in the HMO network
• There usually is NO out of network benefits
• Contracted Rates

I am not quick to recommend an HMO because of the limitations. I do not want my clients to have a problem if they need a top specialist ... as in all likelihood they will be shut out OR the physician will NOT be an HMO provider.

The best features of an HMO are: there is NO deductible, it has more detailed and defined benefits, and it has lower co-pays (but a much higher monthly premium). Your insurance broker can go over the plans available in your market, line by line.

PPO (Prefered Provider Organization)

This is the network where you belong!

Here are the features of a PPO plan:

• Broad network of Physicians which usually includes 90% of all health care facilities available
• There is a deductible, and it varies from $500-$5000 (usually)
• There are benefits that are covered in a PPO, but not an HMO (mental health, chiropractic for example, see your local broker for line by line benefits)
• There are out of network benefits
• Contracted Rates

I prefer a PPO plan for my clients because I would not want any of them to be left out in the cold if they needed that certain top specialist in their market . The key is being able to receive the all important contracted rates , and no matter the deductible the contracted rates are the same . The key here is to stay within your monthly budget . HMO or PPO? PPO is the better option! However there are good HMO's nationwide and they are good for a reason! I can advise you on everything you need to know!

Indemnity Insurance (Fee For Service)

With most indemnity policies you are allowed to choose any doctor and hospital that you would like when looking for health care services. The bonus of traditional fee-for-service insurance is you the customer get to choose. You are given the choice of who and what provider to visit when seeking covered medical services with limited if any geographic limitations. Indemnity policies usually have a deductible; the deductible is the amount you pay before the policies benefits start. Deductibles are usually between $5,000 down to $500, once the deductible has been met the remaining charges are reimbursed to you at the specified percentage noted in your policy. The difference between percentage paid and eligible charges is referred to as the “copayment,” this is usually your responsibility.

Self-Insured Health Plans (Single Employer Self-Insured Plans)

Self-Insured Health Plans are gaining popularity among large employers, labor unions, school districts and other municipalities. These groups provide a pool of money and then pay for the health care services of their members (employees) from this pool. It is common for self-insured plans to turn over the administration of their health plans to a Third Party Administrator (TPA). The TPA handles all administrative tasks including claims processing and payments. Often the employer can contract with an insurance company to act as a TPA for all health care claims. Most self-insured health plans fall under the Employee Retirement Income Security Act (ERISA). ERISA is federal law enforced by the U.S. Department of Labor, Employee Benefits Security Administration (DOL-EBSA). If you are a member of a self-insured health plan through your employer security or union, then you can contact the DOL-EBSA for assistance. The DOL-EBSA does not regulate self-insured health plans that are sponsored through school districts, other municipalities, and or churches. If you are a member of this type of plan, you can file a complaint with the plan directly or you may seek a legal remedy through a court of law. The DOL-EBSA is available to answer questions about self-insured employer plans that come under ERISA regulation. You can gain information on the type of plan that you participate in by contacting your employer or union. If there is still some question, then you can contact the DOL-EBSA for clarification.

Important Points About Self-Insured Health Plans:

• If you work for a large employer, have a union affiliation, work for a school district, or work for a municipality, the health plan offered to you may be a self-insured entity.
• Self-Insured health plans are most likely subject to federal ERISA law.
• If your self-insured health plan is a school district, other municipality, or a church, you may seek assistance from the plan directly or from the courts.
• An insurance company or a third party administrator may administrate a self-insured health plan.
• If your self-insured health plan is not a school district, other municipality, or a church, you can seek help from the DOL-EBSA.

Supplemental Health Insurance

Supplemental health insurance is a type of insurance policy designed to cover the gaps that your regular health insurance may have due to deductibles and co-payments. Supplemental health insurance covers additional expenses that your primary insurance doesn’t cover, such as lost income and living expenses. Those who should consider supplemental health insurance are the self employed, families with children, those financially unprepared to handle large medical bills or time off from work due to illness or injury, and those on Medicare.

Some of the benefits of a supplemental health insurance policy include:
• Cash benefits
• Lower cost due to lower benefit amounts
• The ability to offset lost income unlike a traditional health insurance policy

Common types of supplemental policies are provided by Aflac and then there are MANY supplements regarding Medicare, which doesn’t cover long term health care, at home care, nursing homes, or prescription drugs. Many seniors opt to carry a Medicare supplement in addition to long term care insurance, which protects their financial security.

COBRA, What is COBRA?

What is COBRA continuation health coverage?

Congress passed the landmark Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions in 1986. The law amends the Employee Retirement Income Security Act, the Internal Revenue Code and the Public Health Service Act to provide continuation of group health coverage that otherwise might be terminated.

What does COBRA do?

COBRA provides certain former employees, retirees, spouses, former spouses, and dependent children the right to temporary continuation of health coverage at group rates. This coverage, however, is only available when coverage is lost due to certain specific events. Group health coverage for COBRA participants is usually more expensive than health coverage for active employees, since usually the employer pays a part of the premium for active employees while COBRA participants generally pay the entire premium themselves. It is ordinarily less expensive, though, than individual health coverage.

Who is entitled to benefits under COBRA?

There are three elements to qualifying for COBRA benefits. COBRA establishes specific criteria for plans, qualified beneficiaries, and qualifying events:
• Plan Coverage
• Qualified Beneficiaries
• Qualifying Events

COBRA is a Federal Law that has many technicalities and provisions if you have a specific question please contact us at 1-888-268-4421 or via email or for further reading about the COBRA Law please visit the governments web site about COBRA at The United States Department of Labor.

HIPAA Health Insurance Portability and Accountability Act

On August 21, 1996, then President Bill Clinton, signed Public Law 104-191 (Health Insurance Portability and Accountability Act of 1996 (HIPAA). To improve the efficiency and effectiveness of the health care system, HIPAA includes a series of “administrative simplification” (AS) procedures that required the Department of Health and Human Services (HHS) to adopt national standards for electronic health care transactions. By ensuring consistency throughout the industry, these national standards will make it easier for health plans, doctors, hospitals and other health care providers to process claims and other transactions electronically. The law also requires the adoption of security and privacy standards in order to protect personal health information.

Medicaid and Nevada Check-Up Recipients Helpful Hints About Managing Your Health Information The Health Insurance Portability and Accountability Act (HIPAA) establishes standards to protect the privacy of the health information that the Division of Health Care Financing and Policy (DHCFP) keeps about you.

You can ask us for a copy of your records, authorize others to receive a copy, ask us to make corrections or changes to your record, and request a list of the times that your health information has been shared with others. For further information regarding HIPAA give us a call at 1-888-268-4421or please check with the Nevada Department of Health and Human Services web site.

Nevada State Sponsored Health Resources

Nevada Medicaid State Plan:
Las Vegas Medicaid District Office
1210 S. Valley View
Suite 104
Las Vegas, NV 89102
Main Number: (702) 668-4200

Nevada Check Up:
Division of Health Care Financing and Policy
Nevada Check Up & Nevada Check Up Plus
1000 E. William Street, Suite 200
Carson City, Nevada 89701
Telephone No.: (775) 684-3777
Fax: (775) 684-8792
Toll Free (in-state): 1 (877) 543-7669
Toll Free (out-of-state): 1-800-360-6044

Nevada Check Up PLUS
Telephone No.: (775) 684-3777
Fax: (775) 684-8792
Toll Free (in-state): 1 (877) 543-7669
Toll Free (out-of-state): 1-800-360-6044

Nevada Covering Kids & Families
Northern Office:
C/O Access to Health Care Network,
4001 S Virginia Street Suite F
Reno, Nevada 89502

Southern Office:
6830 W. Oquendo Road, Suite 102,
Las Vegas, NV 89118

Nevada Healthy Kids
Offices:

Carson City
1100 East William Street
Suite 101
Carson City, NV 89701
Main Number: (775) 684-3676

Elko
1010 Ruby Vista Drive
Suite 103
Elko, NV 89801
Main Number: (775) 753-1191

Las Vegas Medicaid District Office
1210 S. Valley View
Suite 104
Las Vegas, NV 89102
Main Number: (702) 668-4200

Reno
1030 Bible Way
Reno, NV 89502
Main Number: (775) 687-1900

This is just a partial list of Nevada's Hardship Health Resource. Please check the States website for more information.

Nevada State Senators:

Senator John Ensign
Phone:1-202-224-6244(DC Office)
Senator Ensign's web page
Email Senator Ensign.

Senator Harry Reid
Phone:1-202-224-3542(DC Office)
Senator Reid's web page
Email Senator Reid.

Nevada House of Representatives:

Shelley Berkley (1st District)
Phone:1-202-225-5965(DC Office)
Representative Berkley's web page
Email Representative Berkley

Dean Heller (2nd District)
Phone:1-202-225-6155(DC Office)
Representative Heller's web page
Email Representative Heller.

Dina Titus (3rd District)
Phone:1-202-225-3252(DC Office)
Representative Titus web page
Email Representative .

Health Insurance Terms:

Assignment of Benefits - Your signed authorization to your doctor or hospital (medical provider) assigning payment to be made directly to them for your medical treatment.

Business Day - Every day that insurance companies are open for business, which excludes Saturday, Sunday, and state and federal holidays.

Calendar Day - Every day of the calendar month, which includes Saturday, Sunday, and state and federal holidays. However, if any action tied to a time frame in an insurance policy falls on a Saturday, Sunday, or state or federal holiday; then the action is postponed to the next calendar day that does not fall on a Saturday, Sunday, or state or federal holiday.

Certificate of Coverage - A document issued to a member of a group health insurance plan showing evidence of participation in the insurance.

Certificate of Creditable Coverage - A written statement from your prior insurance company or health plan documenting the length of time you were covered.

Creditable Coverage or Prior Qualifying Coverage - The number of months you had health insurance in place before your current or new policy became effective. Creditable coverage must be counted towards any preexisting condition exclusion in either an individual or group policy.

Claim - A notification to your insurance company that payment is due under the policy provisions.

Copayment - The portion of charges you pay to your provider for covered health care services in addition to any deductible.

Coverage - The scope of protection provided by an insurance contract which includes any of the listed benefits in an insurance policy.

Denial - An insurance company decision to withhold a claim payment or preauthorization. A denial may be made because the medical service is not covered, not medically necessary, or experimental or investigational.

Deductible - A fixed amount which is deducted from eligible expenses before benefits from the insurance company are payable.

ERISA - Stands for the Employee Retirement Income Security Act (1974). Administered by the U.S. Department of Labor, Employee Benefits Security Administration. ERISA regulates employer sponsored pension and insurance plans (self-insured plans) for employees.

Exclusions and/or Limitations - Conditions or circumstances spelled out in an insurance policy which limit or exclude coverage benefits. It is important to read all exclusion, limitation, and reduction clauses in your health insurance policy or certificate of coverage to determine which expenses are not covered.

Experimental and/or Investigational Medical Services - A drug, device, procedure, treatment plan, or other therapy which is currently not within the accepted standards of medical care.

Grace Period - A specified period immediately following the premium due date during which a payment can be made to continue a policy in force without interruption. This applies only to Life and Health policies. Check your policy to be sure that a grace period is offered and how many days, if any, are allowed.

Guaranteed Issue - A health insurance policy that must be issued regardless of any preexisting medical condition. The present and past physical condition of a health insurance applicant is not considered as a part of underwriting. No physical examination is required. The insurance company cannot decline coverage to an applicant of a guaranteed issue policy based on medical history.

Independent Medical Review - A process where expert medical professionals who have no relationship to your health insurance company or health plan review specific medical decisions made by the insurance company.

Medically Necessary - A drug, device, procedure, treatment plan, or other therapy that is covered under your health insurance policy and that your doctor, hospital, or provider has determined essential for your medical well-being, specific illness, or underlying condition.

Policy - The written contract between an individual or group policyholder and an insurance company. The policy outlines the duties, obligations, and responsibilities of both the policyholder and the insurance company. A policy may include any application, endorsement, certificate, or any other document that can describe, limit, or exclude coverage benefits under the policy.

Preexisting Condition - Any illness or health condition for which you have received medical advice or treatment during the six months prior to obtaining health insurance. Group healthcare policies cover preexisting conditions after you have been insured for 6 months, and individual policies cover preexisting conditions after you have been insured for 1 year.

Usual, Reasonable, and Customary - The amount that your insurance company determines is the normal payment range for a specific medical procedure performed within a given geographic area. If the charges you submit to your health insurance company are higher than what is considered normal for the covered health care services, then your health insurance company may not allow the full amount charged to you.

If You Have Any Questions Or Comments Please Call Or Email Us At: 1-888-268-4421
Email: info@las-vegas-health-insurance-expert.com

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Our Goal Is To Deliver The Best Value Backed By Unmatched Service. We Know Who We Work For... YOU!

Health Insurance Info:

Las Vegas Health Insurance Expert:

How Insurance Works

Types Of Las Vegas Health Insurance

Our Goal Is To Deliver The Best Value Backed By Unmatched Service.
We Know Who We Work For... YOU!