Small business’ role in children’s health insurance

What role do small business owners have in providing health coverage for children of employees?

This question is increasingly significant as the federal government stalls and is apparently unwilling to issue funding for ‘CHIP’ programs for moderate income families that have historically been supported by the majority of lawmakers. Recent news reports indicate that the Senate is unlikely to approve the funding so states and employee benefits advisers like us are beginning to investigate alternatives. This article is meant to provide a preliminary checklist.

  1. Small businesses are not required to provide health insurance to employees.
  2. Businesses that do provide health insurance to employees are not required to provide it (or even make it available) to employees’ children.
  3. Businesses that do provide employee health coverage typically cover children on the same plan and under the same terms as the employees.
  4. Until 2010, the United States was making strong positive progress in providing health coverage to low income children. I covered this topic here in 2011. Most of these initiatives were replaced by the Affordable Care Act (ACA).
  5. The implementation of the ACA dominated coverage from 2012 until this year, 2017. This federal law treated all low income people equally (although coverage varied depending on state and local markets).
  6. The rollback of funding for ACA is the primary factor affecting children’s health insurance for lower income families in 2018.
  7. The cost of children’s health insurance is less than the cost of adult coverage
  8. In many cases small businesses are wise, considering all the options and current laws, to provide supplemental health coverage and avoid providing primary health coverage to employees and their dependents.
  9. Employee health plans can be modified to provide relief for employees’ children in the event of a cancellation of CHIP programs without disturbing other employer policies that are currently in force.

This blog post offers generalized comments for public presentation. Discussion is not customized for each state’s laws. Some of these points may not apply to your firm. Please seek individual guidance that applies to your firm and your state’s laws.

2018 health insurance: 4 simple priorities to consider now

Health care can be complicated. It helps to stay focused on the big decision issues and know that help is available if you need it. It may help to focus on these four simple priorities this month:

  1. PLAN AHEAD: The cost of health coverage can be up to almost 20% of total household income for middle class people in the $50,000 to $100,000 income range. This is a tremendous financial burden that needs to be part of your overall long term financial plan. No political solution will make this problem go away; it is up to you. Take control now by doing what is necessary to protect yourself.
  2. QUALIFY FOR A TAX CREDIT: Most people – about 4 out of 5 people – who need health insurance qualify for reduced-cost coverage made possible by income tax credits that are advanced through your insurance company. It is important to have your online application for 2018 at healthcare.gov* complete by December 15 so get an early start.
  3. OTHER TAX PLANNING: For the 1 in 5 applicants who do not qualify for a premium subsidy (mostly self-employed people or early retirees with income over $100,000)  it takes serious financial planning to cover this expense. Some relief may be available through smart tax planning to cover the expense on a tax exempt basis that saves thousands.
  4. FIND AN ALTERNATIVE: If you can’t afford this type of Obamacare coverage, there are two important next steps are: 1) qualify for a waiver of the tax penalty, and 2) enroll in an alternate less expensive health plan that might cover less but is better than being unprotected.

Freedom Benefits can offer free help with any of these four priorities.

Effects of federal government halt to health insurance subsidies

The federal government has announced that it will not pay scheduled benefits called Cost Sharing Reductions for lower income working class people who buy their own health insurance. It turns out that relatively few people are actually affected. Here are six things for consumers to know:

  1. In most cases the action does not directly affect the amount your pay for insurance. A ‘subsidy’ is not the same as a ‘premium tax credit.’ The amount of  premium tax credit is unaffected. In fact, the number of people who qualify for the credit may increase.
  2. Insurers will increase the premium rates for all policyholders. But most of this increase is paid by the federal government. The 15% of policyholders who pay the full premium will pay more unless the increase now qualified them for a premium subsidy.
  3. The amount of ‘out-of-pocket’ payment for lower income policyholders could increase. If so, in some cases it might be possible to adjust your HSA, FSA and payroll tax withholding to nullify the change by an insurer.
  4. Some insurance companies say they already anticipated Trump’s move when they set their 2018 premiums. States granted insurance companies an extra rate increases to make up for the lost federal funding.
  5. No insurance companies have announced their attention to withdraw from any market because of the federal government action.
  6. Employers that want to help employees make up the difference have a range of tax-free options that allow them to do so. Talk to us about the range of options,

Despite the strong public objection to this action, it might turn out to have minimal impact. The larger danger is that low-income individuals will become frustrated or confused about their health benefits and choose to not enroll in subsidized insurance coverage next year.

Introduction of Healthcare Market Certainty and Mandate Relief Act of 2017

I don’t normally spend much time commenting on newly proposed legislation in its earliest stages. However, the two separate major pieces of legislation introduced yesterday deserve some attention. The first piece was the tax reform legislation, I covered impressions of that “Tax Cuts and Jobs Act” bill here. The second proposed bill called “Healthcare Market Certainty and Mandate Relief Act of 2017” addresses health insurance issues by funding insurance subsidies and removing the individual and employer health insurance mandates.

The American Hospital Association published a press release that says:

“Senate Finance Committee Chairman Orrin Hatch (R-UT) and House Ways and Means Chairman Kevin Brady (R-TX) yesterday introduced the Healthcare Market Certainty and Mandate Relief Act of 2017 that would fund cost-sharing reduction payments to health insurers for two years and eliminate temporarily certain Affordable Care Act mandates. The leaders said the proposal would fund the CSRs through 2019. For 2018, carriers would have to meet certain conditions that would be determined in consultation with the secretaries of the departments of Health and Human Services and Treasury. The proposal also would eliminate the ACA’s individual mandate from 2017-2021; eliminate the ACA’s employer mandate from 2015-2017; and expand the use of health savings accounts.”

The link in the description above is to the Senate bill. The House version of the bill is here. I haven’t read either because we understand that the wording is still in flux. (I don’t understand the process of changing a filed bill or whether these are still considered unfiled).

It is significant to note that this bill is separate from the tax reform proposal and will likely proceed on its own route. It seems to me that the proposal, while unorthodox from an actuarial perspective, just might work.

As of November 5, 2017, the bill has not moved forward from The House Ways and Means Committee.

2018 online insurance enrollment web sites

Different enrollment web sites serve different purposes

Health insurance enrollment for 2018 opened on November 1, 2017. In previous years it was possible to enroll for multiple types of insurance on one web site portal that connected different types of insurance. This year, however, insurance companies have taken steps to separate their products. Freedom Benefits recommends that shoppers deliberately separate their online shopping rather than use a combined product portal in order to get the best service and range of product options. Using two different enrollment web services maximizes the different capabilities of each type of insurance. This is a potentially confusing issue that may come up in this year’s health insurance enrollment.

Regular individual major medical insurance (also known as Obamacare) is offered through Healthcare.gov. This is the government-run health insurance web site. Coverage is available in all locations across the United States. Enrollment is only available online and not by telephone.

Supplemental insurance, short term medical insurance, deductible supplement insurance and dental coverage are offered through commercial insurance exchanges like Smart Insurance Marketplace. Not all types of coverage are available in all areas. Enrollment and live support is available by phone but we recommend that you enroll online.

In the past Freedom Benefits pricing and enrollment support was offered together through one exchange portal service. While these older web sites do exist, we n longer endorse them. We do provide support to consumers with questions about any insurance enrollment decision, regardless of the point of enrollment.

Today’s the day!

All year people have asked me about open enrollment in health insurance. Today’s the day! Open enrollment goes until December 15. Coverage starts January 1, 2018. Most people are eligible for affordable coverage and the web site is quite impressive. But there are three things to watch out for:

1- Technical problems on Healthcare.gov. I’ve already been snagged on one technical issue this morning.

2-Lack of navigator help. If you have questions it may be harder to find help due to reduced funding for navigators.

3-Tax complications. The integration between Healthcare.gov and the IRS is stepped up this year. The result, for some people, is difficultly getting advance premium credits. If this happens, most people will need additional help from the exchange staff and this may take some effort.

I offer limited independent free help with health insurance questions through OnlineNavigator web site. This service is not associated with any government agency, program or insurance company. It’s just something that I do as a community service.

Update on the defunding of insurance subsidy payments

The president’s action appears to have backfired from a political perspective. Now up to 3.5 million middle-income Americans must deal with the severe financial consequences. On the other hand, the resulting premium increases from this government action make more low-income people eligible for free or reduced cost coverage in 2018.

Two weeks ago on October 13 President Trump followed through on his threat to remove cost subsidies to health insurance companies that offered coverage to low-income policyholders. The payments were intended to lower policy deductibles and out-of -pocket expenses for individual who cannot afford to pay these out-of-pocket costs.

Some members of Congress and public health policy experts denounced the move that was intended to hurt lower income policyholders.  Liberal-leaning news sharply criticized the move in this broadcast while some people, including Speaker of the House Paul Ryan publicly supported the cancellation of payments. I was outspoken in earlier interviews and blog posts against the change both from a public policy perspective and as a Republican political strategy. Announcements by the White House said that the move was designed to hasten the collapse the health insurance markets. Apparently President Trump or some federal strategists mistakenly thought that without the subsidies, insurance markets could quickly unravel. President Trump was taped said “this will cost the federal government nothing”. He was wrong. Those supporters failed to consider the ability of insurers and states to nullify the effect of this subsidy cancellation action by raising their premium rates for all policyholders. Most of those increases are mostly paid by the federal government through premium tax credits that Congress has already refused to cancel.

Health insurance companies said they will need much higher premiums to make up for the loss of subsidies. Most companies are now raising their rates for 2018 by an average rate of 20%. State insurance departments that regulate insurance premiums are likely to permit the rate increases. In my state of New Jersey the two largest individual health insurance providers (Amerihealth and Horizon Blue Cross Blue Shield of New Jersey)  will raise rates by  16 percent to 28 percent.  In Pennsylvania some premium rates will  rise by more that 30 percent. For discussion purposes, this might mean a $200 to $500 increase in monthly family premium.

Responses to the defunding

We have seen three primary effects of the president’s decision to defund the subsidy payments for low income policyholders:

1)  The states of California, Connecticut, Delaware, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Minnesota, New Mexico, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia, Washington state and the District of Columbia sued the federal government to restore the health benefit payments. Yesterday a federal court judge blocked the lawsuit from moving forward so this action appears to be dead. See this link to the court ruling. Even though the lawsuit was unsuccessful, it’s filing by so many states shows the opposition of state governments to the federal government’s ‘slash and burn’ approach to health care reform.

2)  Insurance companies throughout the nation have raised premium rates on all individual health insurance in response to the executive order. Most states will grant the last minute rate increases for 2018 as requested to avoid risking companies from withdrawing and collapsing the insurance market.

3) More people are dropping coverage. The number of people without health insurance is rising again. In this recent coverage Fox News speculates that the increase is due to confusion created by the president. Last year the federal government spent $110 Billion covering people and reducing the number of uninsured Americans to a record low, Now the number of Americans without insurance may soon return to the previous high levels.

Effect of the defunding

We see three results so far in response to the defunding of subsidies:

1)  No insurers have pulled out of the market and no individual insurance exchanges have closed as the president intended.

2) The 20% of policyholders who pay the full cost of their policy, about  3,500,000 people in total, will be adversely affects. Many of those hurt are self-employed or early retirees living in suburban areas. News coverage this past week made a big deal of the observation that the strong majority of those financially punished by the President’s executive order are among the relatively small group of Americans who support the president.

3) More Americans will qualify for reduced cost and free coverage. The Wall Street Journal covered this topic today. Apparently insurers are now gearing up to market the “free insurance” and that might further deter the President’s efforts to undermine Obamacare. Even people with incomes up to $98,400 (assuming 4 people in the household located in the lower 48 states) receive some insurance premium tax credit.

Individual response to the executive order

Some middle-income people are concerned about the 15% to 20% increase in their health insurance rates as a result of this presidential action.

Lower income people will not likely be able to pay the deductibles on their policy. This does not affect the ability to access medical care but may affect the individual’s credit score. It seems unlikely that medical providers will take legal action against these low-income individuals.

What to do?

For those 3,500,000 Americans hurt by this presidential action, I advise addressing those options on a one-on-one basis with a health care expert as soon as possible. Health care planning should be the core of financial planning. In this circumstance where life and health are at stake, all options should be considered.

Concerns of small businesses in response to the president’s executive order on health care

On October 12, 2017 the president issued an executive order that directed federal government agencies to explore ways to loosen niche types of health insurance. My annotated copy of the execuive order is posted on my web site at http://tonynovak.com/annotated-health-care-executive-order/.

The executive order does not address these immediate concern to small businesses and individuals:

1) Indicate any change in state insurance regulations that prohibit the use of short term medical or limited benefit insurance plans within its borders. This is of special importance in states with the most restrictive and most expensive insurance.

2) Predict how state insurance regulators will react to the sale of already approved limited benefit or short term medical insurance across state borders to residents within its jurisdiction.

3) Indicate how state insurance prohibiting the use of association insurance plans will be affected or persuaded to ease in conjunction with this executive order.

Freedom Benefits is working with insurance companies, business associations and individual business clients to address these issues and close the gap in knowledge where specific health plan solutions are needed. We are especially focused on solutions for New Jersey small businesses since this state has the most restrictive insurance laws in the nation in this market niche.

Freedom Benefits acts as an adviser but not an insurance company, agent, broker, insurance exchange, association health plan or other entity affected by the executive order. We may be paid paid to perform support functions for any of these entities.

Four health care savings you can implement now

Following the signing of the president’s executive order on health care today, much of the news coverage focused on the fact that it will take time for full implementation of the order and it is uncertain whether some provisions will ever be implemented. This blog post focuses on the opposite angle: the topics covered in the executive order that are already available and may be used to lower health costs immediately.

Consider the following four possibilities that may apply individually or to your small business right now:

1) Short term medical insurance is available in 34 states. Policies are issued immediately online with coverage starting as soon as the next day. Extended 11 month policies are already available in about 14 states.

2) Health Reimbursement Arrangements are available to all businesses with employees. Their use was expanded under the 21st Century Cures Act in December for 2017 to allow employers to pay for individual medial insurance. Special purpose HRAs can expand their usefulness of the plan.

3) Health Savings Accounts are available to everyone with qualifying primary high deductible insurance coverage.

4) Limited benefit or mini-med insurance is already available in most states.

I am happy to discuss the applicability of any of these to your situation. My older web site FreedomBenefits.net has more information.

Review of Core Health Insurance 2017

Introduction
I last reviewed Core Health Insurance in 2010 before the implementation of the Affordable Care Act. This review is being update in anticipation of a growth in popularity following the expected eventual cancellation of our current national health plan laws.

This is the old review not yet updated:

SUMMARY
Core Health Insurance is the only insurance available today that offers this unique combination of features: 1) the plan is available on a universal basis without regard to medical history, employment status or other demographics 2) four different levels of benefits offered allow you to select the plan that that matches a price level that you can afford, and 3) benefits are “assignable” to a doctor or hospital so that you do not need to handle the claim paperwork, unlike most types of limited benefit insurance. This policy provides more liberal coverage for pre-existing medical conditions than most other types of individual medical insurance. Like other supplemental insurance plans, it may be combined with other insurance and benefits are paid in addition to other benefits. The primary complaint is that due to the liberal eligibility and pre-existing condition coverage the price for the highest level of benefits is as expensive as many major medical insurance plans. It is important to understand the differences between traditional “major medical” type health insurance and the newer types of “mini-med” type policies including Core Health Insurance.

Intended Use
Almost half of all Americans have significant gaps in their health insurance. Many cannot find affordable health insurance at all due to pre-existing medical conditions. Core Health Insurance provides limited benefits at an affordable price. It is available to all applicants without regard to medical history so this plan is attractive to people with significant pre-existing medical conditions. Core Health Insurance can be combined with other insurance, including  high deductible Health Savings Account (HSA) type insurance,  to increase the overall level of coverage. Core Health Insurance is not full coverage insurance and should not be used to replace major medical insurance.

General Eligibility
All applicants residing in approved states under age 65 are eligible for this coverage. U.S. citizenship is not required. “Child only” policies are not available; dependent children must be covered with an adult on the policy.

Since this is an association type health plan, applicants must join the Association of United Internet Consumers (AUIC.org), included with the insurance application.  The benefits association cost of $2 per month is built into the premium cost as quoted.
Medical Eligibility
Applicants are eligible without regard to medical history. There are no medical questions on the application and an applicant cannot be declined for insurance due to medical history.

Approved States
46 states have approved this coverage as of the date of this article’s most recent revision:
Alabama, Alaska, Arizona, Arkansas, California, Colorado, District of Columbia, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, New York, Nevada, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, Wyoming.

Application for approval to offer insurance has been made in the following states but is not approved as of the date of this article: Connecticut, Maryland, New Jersey, Vermont, and Washington.

Covered Charges

THIS IS LIMITED INDEMNITY COVERAGE. IT IS NOT MAJOR MEDICAL COVERAGE and is not intended to replace other medical coverage. There is a 30-day waiting period for Sickness benefits. A 12-month Pre-existing Condition Limitation applies to the following benefits: Hospital, including First Day Admission, Hospital Standard room, Intensive Care/Cardiac Care Unit, Surgery and Anesthesia. Please see the listing of exclusions and limitations.

Hospital First Day Admission: After the first 12 months that the policy is in force, you will have coverage up to the amount shown in the benefit schedule of the plan You select.

Hospital (Standard): After the first 12 months that the policy is in force, you will have coverage up to the amount shown in the benefit schedule of the plan You select, for standard, board, miscellaneous medical Hospital charges, and general nursing services for each day You are Confined to a hospital due to a covered Injury or Sickness. This benefit is paid in lieu of a benefit payable for Intensive Care/Cardiac Care Confinement.
Intensive Care/Cardiac Care Unit: After the first 12 months that the policy is in force, you will have coverage up to the amount shown in the benefit schedule of the plan You select, for each day You are Confined to a Hospital in an Intensive Care or Cardiac Care Unit due to a covered Injury or Sickness.  This benefit is paid in lieu of a benefit payable for a standard Hospital room.
Maximum Benefit for ALL First Day Admission, Hospital and Intensive Care/Cardiac Care Unit Confinements is 31 days per person per Policy Year.
Surgery: After the first 12 months that the policy is in force, you will have coverage up to the amount shown in the benefit schedule of the plan You select, for surgery performed while Confined to a Hospital or in an Outpatient Surgery Facility resulting from a covered Injury or Sickness. Limited to 1 surgery (Inpatient or Outpatient) per person per Policy Year.

Anesthesia: After the first 12 months that the policy is in force, when a covered surgical procedure is performed, You will have coverage up to the amount shown in the benefit schedule of the Plan You select, for anesthesia and its administration during the surgery. Limited to 1 (Inpatient or Outpatient) per person per Policy Year.
Doctor’s Office Visits: You will have coverage up to the amount shown in the benefit schedule of the plan You select, for a Medically Necessary Doctor Visit due to a covered Injury or Sickness, visits will also be for newborn well-care and routine health examinations and immunizations for children aged 5 and under. Limited to 5 visits per person per Policy Year.
Wellness Visits: You will have coverage up to the amount shown in the benefit schedule of the plan You select, for a routine health examination. Limited to 1 visit per person per Policy Year.
Basic Diagnostic Testing: You will have coverage up to the amount shown in the benefit schedule of the plan You select, for x-rays, laboratory and other diagnostic tests, ordered or performed by a Doctor that are Medically Necessary due to a covered Injury or Sickness. Limited to 5 sittings per person per Policy Year.
Advanced Diagnostic Studies: You will have coverage up to the amount shown in the benefit schedule of the plan You select, for Medically Necessary EEG’s, EKG’s, CT Scan’s and MRI’s.
Emergency Room: You will have coverage up to the amount shown in the benefit schedule of the plan You select, for Medical treatment received by a Doctor in a Hospital Emergency Room for a Medical Emergency due to a covered Injury or Sickness. Limited to 1 visit per person per Policy Year.
Accident Medical Expense Benefit: You will have coverage up to the amount shown in the benefit schedule of the plan You select, for an accidental Injury that requires Medically Necessary care. Initial treatment for the Injury must be received within 30-days of the date of the Injury. Limited to 1 treatment per person per Policy Year and subject to a $100 deductible.
Accidental Death & Dismemberment: You or Your beneficiary will be paid, up to the amount shown in the benefit schedule of the plan You select, ranging from $625 to $10,000, for a covered Injury that results in accidental death. Dismemberment is paid as a percentage of the amount shown in the benefit schedule, please see dismemberment table for specific benefits and limits.

Coverage details may vary from state to state and may change over time. See your own policy for details.

Maximum Benefit

Maximum overall policy benefit is $1 million. In addition, each type of benefit is subject to the maximum benefit amount listed in the chart below.

Value Plan Silver Plan Gold Plan Platinum Plan
*Hospital:
   First Day Admission (Semi-private room or ICU/CCU): $300 $400 $750 $1,000
   Semi-Private Hospital Room and Board per day: $200 $200 $500 $750
   Intensive Care Unit (ICU/CCU)per day: $400 $400 $1,000 $1,500
   Combined Maximum number of covered days (per person per policy year): 31 31 31 31
*Surgery        
   Inpatient $500 $1,000 $2,000 $3,000
   Outpatient $200 $500 $1,000 $2,000
   Maximum number of surgeries (per policy year): 1 1 1 1
*Anesthesia:        
   Inpatient $100 $200 $400 $600
   Outpatient $40 $100 $200 $400
   Combined Maximum number of treatments (per policy year): 1 1 1 1
Doctor Office Visits $50 $50 $100 $100
   Maximum number of visits (per person per policy year): 5 5 5 5
Wellness Visit     $50 $50 $50 $50
   Maximum number of visits (per person per policy year): 1 1 1 1
Diagnostic Testing, X-Rays & Laboratory:
    Basic: $30 $50 $100 $100
   Maximum number of visits (per person per policy year) 5 5 5 5
   Advanced Studies: $250 $500 $750 $1,000
   Maximum number of visits (per person per policy year): 1 1 1 1
Emergency Room $100 $150 $300 $300
    Maximum number of visits (per person per policy year):

For Medical Emergency Only

1 1 1 1
Accident Medical Expense $500 $500 $2,500 $2,500
    Deductible: $100 $100 $100 $100
    Maximum number treatments (per person per policy year): 1 1 1 1
Accidental Death & Disbursement
Primary Insured Covered up to: $2,500 $5,000 $7,500 $10,000
Covered Spouse up to: $1,250 $2,500 $3,750 $5,000
Each Covered Dependant up to: $625 $1,250 $1,875 $2,500

* Subject to waiting period exclusion for pre-existing conditions.

Exclusions
Benefits will not be paid for charges or loss caused by, or resulting from, any of the following:
(1)  Suicide or any intentionally self-inflicted Injury;
(2)  Any drug, narcotic, gas or fumes, or chemical substance voluntarily taken, administered, absorbed or inhaled unless prescribed by, and taken according to the directions of, a Doctor (accidental ingestion of a poisonous substance is not excluded.);
(3)  Commission, or attempt to commit, a felony;
(4)  Participation in a riot or insurrection;
(5)  Driving under the influence of a controlled substance, unless administered on the advice of a Doctor;
(6)  Driving while Intoxicated.  “Intoxicated” will have the meaning determined by the laws in the jurisdiction of the geographical area where the loss occurs.
(7)  Declared or undeclared war or act of war;
(8)  Nuclear reaction or the release of nuclear energy.  However, this exclusion will not apply if the loss is sustained within 180-days of the initial incident and:
(1)  The loss was caused by fire, heat, explosion or other physical trauma which was a result of the release of nuclear energy; and
(2)  The Covered Person was within a 25-mile radius of the site of the release either:
(a)  At the time of the release; or
(b)  Within 24-hours of the start of the release; or
(c)  Occurs while he is in the issue state of this Certificate;
(9)  Routine health checkups or immunizations for Covered Person aged 6 and older except as specifically provided; allergy testing;
(10) Surgery to correct vision or hearing; eyeglasses, contact lenses and hearing aids, braces, appliances, or examinations or prescriptions therefore;
(11) Dental care, x-rays, or treatment other than Injury to natural teeth and gums resulting from an accidental Injury and rendered within 6-months of the Injury;
(12) Spinal manipulations and manual manipulative treatment or therapy or phisotherapy;
(13) Weight loss or modification and complications arising therefrom, including surgery and any other form of treatment for the purpose of weight loss or modification;
(14) Rest cures or custodial care, or treatment of sleep disorders;
(15) Treatment, services or supplies received outside of the U.S. except for acute Sickness or Injury sustained during the first 30-days of travel outside the U.S.;
(16) Normal pregnancy or childbirth, except for Complications of Pregnancy;
(17) Any drug, treatment, or procedure that either promotes or prevents conception or childbirth regardless of what the drug, treatment, or procedure was originally prescribed or intended for;
(18)  (19) Treatment of temporomandibular joint (TMJ) disorders involving the installation of crowns, pontics, bridges or abutments, or the installation, maintenance or removal of orthodontic or occlusal appliances or equilibration therapy;
(20) Cosmetic surgery.  This Exclusion does not apply to reconstructive surgery:
(a)   On an injured part of the body following trauma, infection or other disease of the involved part;
(b)   Of a congenital disease or anomaly of a covered dependent newborn or adopted infant; or
(c)   On a non-diseased breast to restore and achieve symmetry between two breasts following a covered Mastectomy;
(21) The repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices; dentures, partial dentures, braces or fixed or removable bridges;
(22) Treatment or removal of warts, moles, boils, skin blemishes or birthmarks, bunions, acne, corns, calluses, the cutting and trimming of toenails, care for flat feet, fallen arches or chronic foot strain;
(23)  (24) Treatment of Mental or Nervous Disorders, or alcohol or substance abuse, unless specifically provided for under this Certificate;
(25) Prescription medicines;
(26) Any Injury that is caused by flight or travel in, or upon:
(a)   An aircraft or other, craft designed for navigation above or beyond the earth’s atmosphere except as a fare?paying passenger;
(b)   An ultra light, hang?gliding, parachuting or bungi?cord jumping;
(c)   A snowmobile;
(d)   Any two or three wheeled motor vehicle;
(e)   Any off?road motorized vehicle not requiring licensing as a motor vehicle;
(f)     Any watercraft or other craft designed for water use above or beneath the water, except as a fare-paying passenger;
(27)  Any accidental Injury where the Covered Person is the operator of a motor vehicle and does not possess a current and valid motor vehicle operator’s license;
(28)  Services, treatment or loss:
(a)   Rendered in any Veterans Administration or Federal Hospital, except if there is a legal obligation to pay;
(b)   Payable by any automobile insurance policy without regard to fault. (Does not apply in any state where prohibited);
(c)   Which a Covered Person would not have to pay if he did not have insurance;
(d)   Provided by a Doctor, Nurse or any other person who is employed or retained by a Covered Person or who is a member of a Covered Person’s Immediate Family;
(e)   Covered by state or federal worker’s compensation, employers liability, occupational disease law, or similar laws;
(f)     Injury or Sickness sustained while on active duty in the armed forces of any country. Upon receipt of proof of service, we will refund, any unearned premium paid on a pro rata basis;
(29)  Hemorrhoids, tonsils, adenoids, middle ear disorders, any disease or disorder of the reproductive organs unless the loss is incurred at least 6-months after the Covered Person becomes insured under this Certificate;
(30)  Elective treatment or surgery and treatment, procedures, products or services that are experimental or investigative.  “Experimental or Investigative” means a drug, device or medical treatment or procedure that:
(a)   Cannot lawfully be marketed without approval of the United States Food and Drug Administration and approval for marketing has not been given at the time of being furnished;
(b)   Has Reliable Evidence indicating it is the subject of ongoing clinical trials or is under study to determine its maximum tolerated dose, toxicity, safety, efficacy, or its efficacy as compared with the standard means of treatments or diagnosis; or
(c)   Has Reliable Evidence indicating that the consensus of opinion among experts is that further studies or clinical trials are necessary to determine its maximum tolerated dose, toxicity, efficacy, or its efficacy as compared with the standard means of treatment or diagnosis. “Reliable Evidence” means (i) published reports and articles in authoritative medical and scientific literature; (ii) the written protocol(s) of the treating facility or the protocols of another facility studying substantially the same drug, device, medical treatment or procedure; or (iii) the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or medical treatment or procedure.

Waiting period for sickness benefits

There is a 30-day waiting period for sickness benefits under a newly issued policy. This means that expenses for the treatment of an illness are not available for the first month that your new Core Health insurance policy is in force. For example, if your policy starts on June 1 and you become sick on the next week on  June 8, then the medical expenses incurred to treat your illness would not be covered for the entire month of June but would start to be covered on July 1. After your policy has been in force for one month, this waiting period no longer applies.

All medical charges are grouped into one of three general categories: 1) preventative, 2) accident or 3) sickness. Perhaps a simple but  useful way to define a ‘sickness expense’ is to say that it is not a preventative expense nor an expense to treat an accident or injury.

Pre-existing conditions
A hospitalization caused by a pre-existing medical condition is covered only after the policy has been in force for 12 months. The 12-month Pre-existing Condition Limitation applies to the following benefits:  Hospital, including First Day Admission, Hospital Standard room, Intensive Care/Cardiac Care Unit, Surgery and Anesthesia.

There are no limits on other benefits for pre-existing medical conditions, so this makes Core Health Insurance one of the most liberal choices for coverage of pre-existing medical conditions.

PPO Network Providers
You have the freedom to choose any medical service provider. This insurance plan does not require network providers. The same level of benefits is paid to all providers regardless of their PPO network affiliations. Any doctor or hospital may be used. There is no “out-of-network” reduction in benefits.

If a Preferred Provider Organization (PPO) network is available in your area, then you might save money by using a PPO member provider. This feature is automatically added as an available option to your Core Health plan if a PPO network is available in your area.

Benefit payments may be made directly to your doctors and PPO member providers are more likely to accept assignment of benefits. Although the willingness to accept assignment is not controlled by the insurance company, this is frequently a practical advantage of using a PPO member provider. More information about using the optional PPO network is provided on the page “How Core Health Plans Work”.

Referrals
This plan does not require referrals for treatment. Treatment provided by any doctor or hospital in the United States may be covered

Pre-certification
This insurance requires pre-certification within 48 hours of an in-patient hospital admission.

Deductibles
This policy does not use deductibles. The benefits listed in the policy are the exact dollar benefits available; no adjustment is made for deductibles.

Co-payments
This policy does not use co-payments. The benefits listed in the policy are the exact dollar benefits available; no adjustment is made for co-payments.

Co-insurance
This policy does not use co-insurance. The benefits listed in the policy are the exact dollar benefits available; no adjustment is made for co-insurance.

Length of Coverage
The minimum length of coverage is 30 days. There is no maximum length of coverage. Coverage is renewable until age 65 or until canceled by the insured.

Rate Increases

No individuals can be singled out for rate increase under the policy. Rates are anticipates to increase over time in step with overall price increases for health care.

Policy Cancellation

No individuals can be singled out for cancellation under the policy. The insurance company has the right to cancel the policy by providing at least 31 days notice to the association policyholder, AUIC, which, in turn, has 31 days to notify you of the cancellation of coverage. (To cancel your own coverage, see “To Cancel Coverage” below).

Insurance Company
United States Fire Insurance Company is a member of Fairmont Specialty, a division of Crum & Forster. 305 Madison Avenue, Morristown, NJ 07962  Phone: 973-490-6600  Fax: 973-490-6612 (This is the company’s legal address only and is not the address or phone number to use for routine correspondence about your health insurance).

Plan Administrator
Core Health Insurance is administered by SAS-ID, P.O. Box 1086, Janesville WI 53547-1086.  Tel. 877-279-7959, Fax 608-755-7955.  SAS-ID develops technologies and online marketing solutions for top insurance carriers and nationwide distribution networks. SAS-ID was founded in 1999 and has been a leader and innovator in developing and marketing insurance on the web. SAS-ID was founded by insurance professionals who have a passion to make insurance simpler and more accessible to everyone. SAS-ID is a member of the BBB Online Reliability program.

Financial Strength and Ratings
This insurance company is rated A- by A.M. Best, the third-highest rating of 15 possible ratings. with a Financial Size Category XIII ($1.25 Billion to $1.5 Billion). Outlook is listed as positive. This rating was affirmed effective May 4, 2007.

Consumer Complaints
The National Association of Insurance Commissioners (NAIC) collects data on consumer complaints against insurance companies and publishes compiled information on its Web site at www.NAIC.org . The NAIC assigns an “average complaint ratio” as 1.0 measurement. United States Fire Insurance Company received a 0.00 complaint ratio for 2004, 2005 and 2006 which means that there were no customer complaints for health insurance reported to the NAIC.

Consumer Reviews
Since this is a new insurance product, consumer reviews are not yet available. Reviews will be posted on the enrollment web site at www.freedombenefits.org in the near future. If you have a comment or product review, send an e-mail to Health Insurance at tnovak@freedombenefits.org

Price
Price is based on age, location (zip code) and sex of each applicant. Premium rates are available online at the link listed below. Monthly premium rates average about $50 for young adults selecting lower levels of benefits and go much higher ($400 per month or more) for older adults selecting the highest level benefits. The median insurance policy premium is about $200 per month – about half of the cost of major medical insurance but more than most typical limited benefit or supplemental insurance plans.

Enrollment Method
Secure online enrollment is available and this is the preferred method of enrollment. An immediate confirmation of enrollment is sent by email. Enrollment by mail is available by printing and mailing the application (taken from the online enrollment site) and sending with initial payment. No confirmation of enrollment is available for mailed applications; your proof of payment (cashed check or credit card charge) may be used as proof of application.

Billing Method
Most applicants elect to have the policy billed automatically to a credit card or bank account on month-to-month basis. Coverage continues until cancelled.

Another billing option is to have an invoice sent to your resident address.  A modal billing fee will be added to each bill and there is an additional one-time fee of $10 due at time of enrollment to stat the manual billing option.

Payment Method
Premiums may be paid by credit card, debit card, EFT, money order or personal check. Payment may not be made by business check because this would be a violation of many states’ business insurance laws. The most common method of payment is online credit card.

To Cancel Coverage
Mail or Fax a written request for cancellation a minimum of 5 days prior to the monthly billing date. The automatic billing date is the date of the 1st payment made. Any requests received less than 5 days prior to the current month’s billing date will be processed for cancellation before the next month’s billing date. If sending a request by mail, use delivery confirmation with the U.S. Post Office to ensure that the request is received at least five days before the billing date. If using an overnight delivery service, keep the tracking information. If cancelling by fax, call 800-279-2290 extension 207 to confirm receipt of your faxed request. Insurance cancellation requests cannot be accepted by telephone or e-mail.

Include all relevant information in your request: the policy holder’s name & address, the policy holder’s date of birth, the policy ID number, the date the policy is to be cancelled, the reason for cancellation, the policy holder’s signature.

The fax number is 608-755-7955,

The mailing address is SASid,  462 Midland Rd #100, Janesville, WI 53546


Online Quote and Application
Most short term medical insurance policies are priced and issued directly online. This policy is available through Freedom Benefits. The direct enrollment link is
http://www.quoteintelligence.com/launch.aspx?refnumber=000000161-026-001

Brochure
A product brochure in PDF format is not yet available for download from this site and brochures are not available by mail. As a temporary alternative, the Web pages can be printed.

Paper Applications
Applications may be downloaded and then printed from the enrollment site above and are also available by fax from the enrollment adviser. Applications are not available by mail.

Fax Application
Faxed applications are accepted when paying with a credit card or pre-authorized electronic funds transfer (EFT). Applications may be faxed directly to (888) 581-0748 with assurance of privacy and security of data. When applying by fax, you should confirm receipt of the application separately by telephone or e-mail if an e-mail confirmation is not received within one business day.

Policy Issue Time
An online application is approved immediately at the time you apply for coverage and an acceptance e-mail is sent for confirmation of coverage, subject to the payment being approved.  In most cases the policy and ID cards are mailed in the next business day.

Child-Only Applications
Children can apply only with a covered adult parent or guardian. Child-only applications will not be approved.


ID Cards
This policy uses plastic ID cards that are sent by mail when the policy is issued, usually within one business day after online application. Temporary paper ID cards are available at the time of application by following the link on the confirmation e-mail.

Enrollment Support
Professional enrollment support by e-mail is provided without charge by OnlineAdviserTM at tnovak@freedombenefits.org. This service handles all applicant questions prior to the issuance of a policy.


Member Support
The toll-free telephone number for member support is 877-279-7959. This number is also listed on the insurance ID card.

Billing Support
Toll-free billing support for issued policies is available at 877-279-7959. The mailing address for customer service is SAS-ID, P.O. Box 1086, Janesville WI 53547-1086.  Fax 608-755-7955.

Claims
Claims may be submitted by either the policyholder or a medical service provider. Core Health Insurance is subject to the same 10 day response time laws and claim payment procedures as other health insurance companies. If a medical service provider wants to receive the payment directly from the insurer then an “Assignment of Claim” form signed by the policyholder is required. Otherwise all benefits payments are made to the policyholder.  The claims department phone number is 877-279-7959. The mailing address for claims is SAS-ID, P.O. Box 1086, Janesville WI 53547-1086.  Fax 608-755-7955.

Comments
We welcome policyholder comments about this policy at tnovak@freedombenefits.org.