| |
| Life Insurance |
| Why do I need Life Insurance? |
| Life insurance is an essential
part of financial planning. One reason most
people buy life insurance is to replace income
that would be lost with the death of a wage
earner. The cash provided by life insurance
also can help ensure that your dependents are
not burdened with significant debt when you
die. Life insurance proceeds could mean your
dependents will not have to sell assets to pay
outstanding bills or taxes. An important feature
of life insurance is that no income tax is payable
on proceeds paid to beneficiaries. The death
benefit of a life policy owned by a C corporation
may be included in the calculation of the alternative
minimum tax. |
| |
| How
much Insurance do I need?
|
| Before buying life insurance,
you should assemble personal financial information
and review your family's needs. There are a
number of factors to consider when determining
how much protection you should have. These include: |
- any immediate needs at the time of death,
such as final illness expenses, burial costs
and estate taxes;
- funds for a readjustment period, to finance
a move or to provide time for family members
to find a job
- ongoing financial needs, such as monthly
bills and expenses, day-care costs, college
tuition or retirement.
|
| Although there is no substitute
for a careful evaluation of the amount of coverage
needed to meet your needs, one rule of thumb
used is buy life insurance that is equal to
five to seven times annual gross income. |
| |
| Choosing A Plan |
Buying life insurance is not
like any other purchase you will make. When
you pay your premiums, you're buying the future
financial security of your family that only
life insurance can provide. Among its many uses,
life insurance helps ensure that, when you die,
your dependents will have the financial resources
needed to protect their home and the income
needed to run a household.
Choosing a life insurance product is an important
decision, but it often can be complicated. As
with any other major purchase, it is important
that you understand your needs and the options
available to you.
The main types of life insurance available are
term and permanent. Term insurance provides
protection for a specified period of time. Permanent
insurance provides lifelong protection. |
| |
| Additional Points |
1. What happens if I fail to
make the required payments?
|
If you miss a premium payment, you typically
have a 30- or 31-day grace period during
which you can pay the premium. After that,
the policy will lapse. You may be able
to reinstate with evidence of insurability
depending on your policy's provisions.
If your policy has sufficient cash value,
the company can, with your authorization,
draw from a permanent policy's cash surrender
value to keep that policy in force. This
does not apply to term insurance because
there is no cash value to draw from. In
some flexible premium policies, premiums
may be reduced or skipped as long as sufficient
cash values remain in the policy. However,
this will result in lower cash values.
|
2. What if I become disabled?
|
Provisions or riders that provide additional
benefits can often be added to a policy.
One such rider is a waiver of premium
for disability. With this rider, if you
become totally disabled for a specified
period of time, you do not have to pay
premiums for the duration of the disability.
|
3. Are other riders available?
(*availability
and specifics of these riders vary by carrier
and state.)
|
- "Accidental death benefit", provides
for an additional benefit in case of death
as a result of an accident.
- "Accelerated benefits", also known as
"living benefits." This rider allows you,
under certain circumstances, to receive
the proceeds of your life insurance policy
before you die. Such circumstances include
terminal or catastrophic illness, the
need for long-term care or confinement
to a nursing home.
- "Child rider", provides insurance for
all your children, usually from $1,000
to $20,000 of death benefit.
|
4. When will the policy be
in effect?
|
If you decide to purchase the policy, find
out when the insurance becomes effective.
This could be different from the date the
company issues the policy.
|
5. How do accelerated death
benefits work?
|
It allows policyholders to receive all
or part of the policy's proceeds prior to
death under certain circumstances, including
the need for long-term care and confinement
to a nursing home. Because payments may
affect tax status and Medicare eligibility,
and will be deducted from the overall benefits
paid later to beneficiaries, policyholders
should thoroughly investigate options in
advance.
|
6. By using medical tests are
insurers trying to eliminate any applicant
likely to develop a serious health condition?
|
Medical tests can provide accurate and
current information about an applicant's
health, thus enabling insurers to charge
premiums that reflect the level of risk
an applicant represents. Because some health
conditions are easily managed through proper
medication, therapy or lifestyle changes,
medical information sometimes makes it possible
for insurers to cover applicants who might
not otherwise be insurable. More serious
or incurable conditions present an enormous
risk that an insurer simply cannot assume.
|
7. What should I consider in
naming life insurance beneficiaries?
|
- Always name a "contingent," or secondary,
beneficiary, just in case you outlive
your first beneficiary.
- Select a specific beneficiary, rather
than having the proceeds of your life
insurance paid to your estate. One of
the great advantages of life insurance
is that it can be paid to your family
immediately. If it is payable to your
estate, however, it will have to go through
probate with the rest of your assets.
- Be very clear in wording beneficiary
designations. Naming specific children
may exclude those born later. If your
child dies before you, do you want the
proceeds to go to that child's children?
Changing the beneficiary designation is
easy, but you have to remember to do it.
|
8. Does it make sense to replace
a policy
|
Think twice before you do, because in many
situations it may not be to your advantage.
Before dropping any in-force policy, make
sure your "new" policy is paid for and in
effect and first consider:
|
- If your health status has changed over
the years, you may no longer be insurable
at preferred or standard rates.
- Even if both policies pay "dividends,"
it may be years before the new policy's
dividends equal those of your present
one.
- If you replace one cash-value policy
with another, the cash value of the new
policy may be relatively small for several
years and may never be as large as that
of the original one. There may also be
a period wherein a surrender charge is
applicable on the first policy.
- You should ask for a detailed listing
of cost breakdowns of both policies, including
premiums, cash surrender value and death
benefits. Compare these as well as the
features offered by both policies.
- If you decide to surrender or reduce
the value of the policy you now own and
replace it with other insurance, be sure
your new policy is in force before you
cancel the old one.
|
9. As a single person, do I
need insurance?
|
The answer almost always is yes. You may
want to consider these options:
|
- Disability income insurance - especially
important for self-supporting singles
without sizable assets, this can replace
a good part of the income you would lose
if you were unable to work because of
accident or illness. If you don't have
long-term disability coverage at work,
it would be wise to consider an individual
policy designed to replace at least 60
percent of your income.
- Health insurance - if you don't have
on-the-job coverage, an individual policy
is your first line of defense against
ever-escalating medical and hospital costs.
You can keep premium costs down by electing
a large deductible, thereby "self-insuring"
as much as you can afford.
- Life insurance - even if you have no
dependents now, you may later. If you
buy now when you are younger and healthier,
you an "lock in" lowest-cost coverage,
including guaranteed insurability.
|
|
| |
| Long Term-Care Insurance |
| What
is Long-Term Care? |
| Long-term care is the assistance
individuals need when they are unable to care
for themselves and need help with Activities
of Daily Living (ADLs) - bathing, dressing,
transferring, toileting, continence (control
of bodily functions), and eating - or they have
severe cognitive impairment such as Alzheimer's
disease. The need for long-term care can result
from an accident, chronic illness or short-term
disability, or from advance age. Long term care
can include a broad range of services, provided
in any setting outside a hospital. It might
be help with simple daily tasks like bathing
or dressing. It might include skilled care in
your own home, an assisted living facility,
some other community resources, or a nursing
facility. |
| |
| Who
Needs Long-Term Care? |
- In the year 2002 about seven
million men and women over age 65 needed
long-term care. (HIAA, "A Guide to Long-Term
Care Insurance", 2002)
- By 2005, the number will
increase to nine million. (HIAA, "A Guide
to Long-Term Care Insurance", 2002)
- By 2020, 12 million older
Americans will need long-term health care.
(HIAA, "A Guide to Long-Term Care Insurance",
2002)
- Family and friends are the
sole caregivers for 70% of elderly people
and most will cared for at home. (HIAA,
"A Guide to Long-Term Care Insurance", 2002)
- People age 65 or older face
at least a 40% lifetime risk of entering
a nursing home. 10% will stay more than
five years. (HIAA, "A Guide to Long-Term
Care Insurance", 2002)
- 22% of people over age 85
are in a nursing home. (HIAA, "A Guide to
Long-Term Care Insurance", 2002)
- Women, because they outlive
men, face a 50% greater likelihood of entering
a nursing home after age 65. (HIAA, "A Guide
to Long-Term Care Insurance", 2002)
|
| |
| Some Misconceptions about Medicaid and Medicare |
Medicaid
Medicaid pays for health services for the very
poor of any age. Qualifications for Medicaid
vary by state, but generally the law says you
must first spend down to the poverty level,
using up all but about $2,000 of your assets.
Being eligible for Medicaid does not guarantee
placement in a nursing home. There may be long
waiting lists for facility care. Depending on
the state and facility, Medicaid patients often
receive lesser-quality care than patients who
are paying on their own. Under Medicaid, nursing
home care is essentially the only option. Home
care, assisted living facility care, adult daycare,
outpatient services, and alternate caregiver
services are not usually reimbursed under Medicaid.
|
Medicare
Medicare pays for health care for people 65
and over and for those who are disabled. Medicare
does not pay for long term medical service such
as assisted living or adult day care. Medicare
pays only the first 100 days of skilled care,
such as physical therapy or nursing, which only
accounts for 5% of all long term care costs.
You are eligible for the care only if you have
been in the hospital for at least three days.
The personal care must relate to the treatment
of an illness or injury. Medicare pays 100%
for the first 20 days and all but the first
$95 per day for the next 80 days.
Medicare supplement insurance is a private insurance
that helps pay for some gaps in Medicare coverage.
Plans D, G, I, and J do pay up to $1,600 per
year for services to people recovering at home
from an illness, injury, or surgery |
| |
| Exceptions, Limitations and
Exclusions |
| Most long term care insurance
policies will not pay benefits for any confinement,
care, treatment, or service(s): |
- That results from attempted suicide or
intentionally self-inflicted injury;
- That results from voluntary participation
in a felony, attempted felony, or illegal
occupation;
- That results from a sickness or injury
for which benefits are provided under any
state or federal worker's compensation law;
- Provided outside the United States or
Canada;
- Provided in a government facility (unless
otherwise required by law);
- Provided for the treatment of alcoholism
or drug addiction, or in facilities operated
primarily for such treatment;
- Provided in facilities operated primarily
for the treatment of mental or nervous disorders
or disease, other than Alzheimer's disease
or dementia.
|
| |
| Pre-existing Conditions |
| You could be declined coverage
if you already have the following condition(s):
|
- Alzheimer's Disease;
- Severe Arthritis with functional limitations;
- Diabetes which is not under control;
- Cancer within the past 6 months;
- Parkenson's Disease;
- Stroke within the past 6 months;
- A Stroke at any time, which has caused
functional limitations;
- Congestive Heart Failure within the past
6 months;
- Emphysema, if severe or still smoking;
- Chronic Obstructive Pulmonary Disease,
if severe or still smoking;
- Any conditions which require the assistance
of another human being for the basic activities
of daily living: bathing, eating, toileting,
or transferring in and out of a bed or chair
|
|
| |
| Disability Insurance |
| Protects your most valuable asset
and your ability to earn an income. |
- Each year 12% of the adult population
suffer a long term disability.
- 1 out of every 7 workers will suffer a
five-year or longer disability before reaching
age 65.
- At age 32 your chances of suffering a
three-month or longer disability is 6 times
more likely than death
- At age 35 your chances of suffering a
three-month or longer disability is 50%
- At age 45 your chances of suffering a
three-month or longer disability is 44%
- On average 7 out of 10 claims for Social
Security disability benefits are refused
the first time requested.
|
| Statistics
were obtained from Commissioner's Disability
Tables and the Senate Finance Committee. |
| |
| Disability insurance pays cash
benefits to the policyholder in the event the
insured is unable to work due to sickness or
injury. That cash benefit ranges from 50% to
70% of income. The insurance company will not
pay more than 70% of income because there must
be an incentive to return to work. |
- If you pay the premium the benefits are
normally received free from income tax,
if the premiums are paid by an employer,
the benefits are taxable as ordinary income.
|
| |
| A disability policy is composed
of various elements: |
- Elimination Period - It is the period
of time the insured must wait after becoming
disabled to receive benefits. Typical waiting
periods are 30, 60, 90,120,180, and 360
days. The longer the elimination period
the less expensive the policy.
- Benefit Period - It is the period of time
the benefits will be paid following the
elimination period. The benefit period could
be from 2 years to age 65 to lifetime. The
longer the benefit period the more expensive
the policy.
- The Amount of Benefit - The larger the
pay-out the more expensive the policy. The
benefit will not normally exceed 70% of
income.
- Residual Benefit - Percentage of benefit
paid if you return to work and are still
partially disabled and cannot return to
work full time or cannot earn your full
income.
- Own-Occupation - Pays a benefit if you
are unable to return to your present occupation
but can work doing something else. For example,
a doctor who is a surgeon, cannot return
to surgery but can teach. This is the most
expensive type of disability policy.
- Reasonable or Any Occupation - Pays a
benefit while disabled, but stops when you
are able to return to work at a job that
matches your education and experience. This
policy is less expensive than an Own-Occupation
policy.
- Occupation - Occupation is a factor used
in determining rates. For example, a doctor's
rate would be much lower than a blue-collar
worker.
- Guaranteed Renewable - Guaranteed Renewable
policies cannot be cancelled by the insurance
company even if a change in the insured's
circumstances would make him or her a greater
risk. Plus, the insurance company cannot
make any changes to the provisions of the
policy, or add restrictions. When purchasing
an individual disability policy it should
be Guaranteed Renewable.
- Non-Cancelable - Guarantees future premiums
will not be increased. When purchasing an
individual policy it should be Non-Cancelable.
- Presumptive Disability - Presumptive disability
means that you are considered total disabled
and eligible for benefits for the loss of
sight in both eyes or the loss of two limbs.
The better contracts also presume total
disability for the loss of hearing in both
ears, loss of the power of speech, or the
loss of the use of two limbs.
|
| |
| Other Benefits that can be added
to an individual disability policy, but could
also increase the cost: |
- Protection Against Inflation - A benefit
that can be added that offers a cost-of-living
adjustment for inflation during a long-term
claim.
- Automatic Increase Rider - Automatically
increases monthly benefits for a specified
period of time. A typical increase is 5%
compound.
- Future Increase Options - Allows the insured
to purchase additional benefit amounts without
proof of insurability.
- Capital Sum Benefit - Pays the insured
a lump sum benefit up to 12 times the monthly
benefit if the insured loses the sight of
one eye with no possibility of recovery
or has a hand or foot severed. This benefit
is paid in addition to the other benefits.
- Rehabilitation Benefit - To help a disabled
insured return to work, this benefit will
pay some of the expenses incurred when the
insured enrolls in an approved rehabilitation
center. This benefit is paid in addition
to the other benefits.
- Transplant & Cosmetic Surgery Benefit
- Under this benefit, any disability arising
from donating a transplant organ, improving
your appearance or correcting a disfigurement
will be covered by the policy.
|
| |
| Types of Coverage |
| Social Security |
- Social Security does not just provide
for retirement income but disability income
as well. However, more than 70% of the applicants
who apply, fail to get coverage the first
time they apply. You can get an estimate
of what your benefit might be by going to
the Social Security web site.
- In 1992, the average monthly payment for
a disabled worker was $642; the average
monthly payment for a family of a disabled
worker was $1093.
- Eligibility is based on being unable to
perform any gainful employment.
- You are eligible for benefits after you
have been disabled for 5 months and if the
disability is expected to last 12 months.
- 85% of Social Security disability payments
are subject to federal income tax if your
income exceeds $34,000 individually or $44,000
jointly.
|
| Workers Compensation
|
Most employers are required to provide
this coverage. The amount and duration varies
by state. Workers Compensation only pays
if the disability occurs on the job, and
usually lasts for only a few years and the
payments are low.
|
| Individual Policies |
For individual policies, the applicant
needs to qualify and go through an underwriting
process, similar to the process required
for life insurance. The applicant could
be subject to a higher premium or even be
declined based on his or her occupation,
medical history, or lifestyle. Individual
policies are usually purchased by high income
professionals because of the cost.
|
| Group Policies |
Some states require employers to carry
group disability insurance anywhere from
26 to 52 weeks.
|
| Group Long Term Disability
(LTD) |
Group LTD is carried by almost half of
mid-size to large employers and provides
long term benefits for at least 5 years
covering about 60% of salary. The premium
is usually very low, does not require proof
of insurability, and often is fully paid
by the employer.
|
|
| |
| Health Insurance Options |
Today, health care costs
are high, and getting higher. Who will pay your
bills if you have a serious accident or a major
illness? You buy health insurance for the same
reason you buy other kinds of insurance, to
protect yourself financially. With health insurance,
you protect yourself and your family in case
you need medical care that could be very expensive.
You can't predict what your medical bills will
be. In a good year, your costs may be low. But
if you become ill, your bills could be very
high. If you have insurance, many of your costs
are covered by a third-party payer, not by you.
A third-party payer can be an insurance company
or, in some cases, it can be your employer.
Health care in America is changing rapidly.
Twenty-five years ago, most people in the United
States had indemnity insurance coverage. A person
with indemnity insurance could go to any doctor,
hospital, or other provider (which would bill
for each service given), and the insurance and
the patient would each pay part of the bill.
But today, more than half of all Americans who
have health insurance are enrolled in some kind
of managed care plan, an organized way of both
providing services and paying for them. Different
types of managed care plans work differently
and include preferred provider organizations
(PPOs), health maintenance organizations (HMOs),
and point-of-service (POS) plans.
You've probably heard these terms before. But
what do they mean, and what are the differences
between them? And what do these differences
mean to you? |
| |
| Types
of Insurance |
| Fee-for-Service (Indemnity
Plan)
|
| This is the traditional kind
of health care policy. Insurance companies pay
fees for the services provided to the insured
people covered by the policy. This type of health
insurance offers the most choices of doctors
and hospitals. You can choose any doctor you
wish and change doctors any time. You can go
to any hospital in any part of the country.
|
| With fee-for-service, the insurer
only pays for part of your doctor and hospital
bills. This is what you pay: |
- A monthly fee, called a premium.
- A certain amount of money each year, known
as the deductible, before the insurance
payments begin. In a typical plan, the deductible
might be $250 for each person in your family,
with a family deductible of $500 when at
least two people in the family have reached
the individual deductible. The deductible
requirement applies each year of the policy.
Also, not all health expenses you have count
toward your deductible. Only those covered
by the policy do. You need to check the
insurance policy to find out which ones
are covered.
- After you have paid your deductible amount
for the year, you share the bill with the
insurance company. For example, you might
pay 20 percent while the insurer pays 80
percent. Your portion is called coinsurance.
|
To receive payment for fee-for-service
claims, you may have to fill out forms and send
them to your insurer. Sometimes your doctor's
office will do this for you. You also need to
keep receipts for drugs and other medical costs.
You are responsible for keeping track of your
medical expenses
.
There are limits as to how much an insurance
company will pay for your claim if both you
and your spouse file for it under two different
group insurance plans. A coordination of benefit
clause usually limits benefits under two plans
to no more than 100 percent of the claim.
Most fee-for-service plans have a "cap," the
most you will have to pay for medical bills
in any one year. You reach the cap when your
out-of-pocket expenses (for your deductible
and your coinsurance) total a certain amount.
It may be as low as $1,000 or as high as $5,000.
Then the insurance company pays the full amount
in excess of the cap for the items your policy
says it will cover. The cap does not include
what you pay for your monthly premium.
Some services are limited or not covered at
all. You need to check on preventive health
care coverage such as immunizations and well-child
care.
There are two kinds of fee-for-service coverage:
basic and major medical. Basic protection pays
toward the costs of a hospital room and care
while you are in the hospital. It covers some
hospital services and supplies, such as x-rays
and prescribed medicine. Basic coverage also
pays toward the cost of surgery, whether it
is performed in or out of the hospital, and
for some doctor visits. Major medical insurance
takes over where your basic coverage leaves
off. It covers the cost of long, high-cost illnesses
or injuries.
Some policies combine basic and major medical
coverage into one plan. This is sometimes called
a "comprehensive plan." Check your policy to
make sure you have both kinds of protection.
|
| |
| What
Is a "Customary" Fee? |
| Most insurance plans will pay
only what they call a reasonable and customary
fee for a particular service. If your doctor
charges $1,000 for a hernia repair while most
doctors in your area charge only $600, you will
be billed for the $400 difference. This is in
addition to the deductible and coinsurance you
would be expected to pay. To avoid this additional
cost, ask your doctor to accept your insurance
company's payment as full payment. Or shop around
to find a doctor who will. Otherwise you will
have to pay the rest yourself. |
| |
| Questions to Ask About Fee-for-Service (Indemnity) Insurance
|
- How much is the monthly premium?
What will your total cost be each year?
There are individual rates and family rates.
- What does the policy cover?
Does it cover prescription drugs, out-of-hospital
care, or home care? Are there limits on
the amount or the number of days the company
will pay for these services? The best plans
cover a broad range of services.
- Are you currently being treated
for a medical condition that may not be
covered under your new plan? Are there limitations
or a waiting period involved in the coverage?
- What is the deductible? Often,
you can lower your monthly health insurance
premium by buying a policy with a higher
yearly deductible amount.
- What is the coinsurance rate?
What percent of your bills for allowable
services will you have to pay?
- What is the maximum you would
pay out of pocket per year? How much would
it cost you directly before the insurance
company would pay everything else?
- Is there a lifetime maximum
cap the insurer will pay? The cap is an
amount after which the insurance company
won't pay anymore. This is important to
know if you or someone in your family has
an illness that requires expensive treatments.
|
| |
| Health Maintenance Organizations (HMOs) |
Health maintenance organizations
are prepaid health plans. As an HMO member,
you pay a monthly premium. In exchange, the
HMO provides comprehensive care for you and
your family, including doctors' visits, hospital
stays, emergency care, surgery, lab tests, x-rays,
and therapy.
The HMO arranges for this care either directly
in its own group practice and/or through doctors
and other health care professionals under contract.
Usually, your choices of doctors and hospitals
are limited to those that have agreements with
the HMO to provide care. However, exceptions
are made in emergencies or when medically necessary.
There may be a small co-payment for each office
visit, such as $5 for a doctor's visit or $25
for hospital emergency room treatment. Your
total medical costs will likely be lower and
more predictable in an HMO than with fee-for-service
insurance.
Because HMOs receive a fixed fee for your covered
medical care, it is in their interest to make
sure you get basic health care for problems
before they become serious. HMOs typically provide
preventive care, such as office visits, immunizations,
well-baby checkups, mammograms, and physicals.
The range of services covered vary in HMOs,
so it is important to compare available plans.
Some services, such as outpatient mental health
care, often are provided only on a limited basis.
Many people like HMOs because they do not require
claim forms for office visits or hospital stays.
Instead, members present a card, like a credit
card, at the doctor's office or hospital. However,
in an HMO you may have to wait longer for an
appointment than you would with a fee-for-service
plan.
In some HMOs, doctors are salaried and they
all have offices in an HMO building at one or
more locations in your community as part of
a prepaid group practice. In others, independent
groups of doctors contract with the HMO to take
care of patients. These are called individual
practice associations (IPAs) and they are made
up of private physicians in private offices
who agree to care for HMO members. You select
a doctor from a list of participating physicians
that make up the IPA network. If you are thinking
of switching into an IPA-type of HMO, ask your
doctor if he or she participates in the plan.
In almost all HMOs, you either are assigned
or you choose one doctor to serve as your primary
care doctor. This doctor monitors your health
and provides most of your medical care, referring
you to specialists and other health care professionals
as needed. You usually cannot see a specialist
without a referral from your primary care doctor
who is expected to manage the care you receive.
This is one way that HMOs can limit your choice.
Before choosing an HMO, it is a good idea to
talk to people you know who are enrolled in
it. Ask them how they like the services and
care given. |
| |
| Questions to Ask About an HMO |
- Are there many doctors to
choose from? Do you select from a list of
contract physicians or from the available
staff of a group practice? Which doctors
are accepting new patients? How hard is
it to change doctors if you decide you want
someone else? How are referrals to specialists
handled?
- Is it easy to get appointments?
How far in advance must routine visits be
scheduled? What arrangements does the HMO
have for handling emergency care?
- Does the HMO offer the services
I want? What preventive services are provided?
Are there limits on medical tests, surgery,
mental health care, home care, or other
support offered? What if you need a special
service not provided by the HMO?
- What is the service area
of the HMO? Where are the facilities located
in your community that serve HMO members?
How convenient to your home and workplace
are the doctors, hospitals, and emergency
care centers that make up the HMO network?
What happens if you or a family member are
out of town and need medical treatment?
- What will the HMO plan cost?
What is the yearly total for monthly fees?
In addition, are there copayments for office
visits, emergency care, prescribed drugs,
or other services? How much?
|
| |
| Preferred Provider Organizations (PPOs) |
The preferred provider organization
is a combination of traditional fee-for-service
and an HMO. Like an HMO, there are a limited
number of doctors and hospitals to choose from.
When you use those providers (sometimes called
"preferred" providers, other times called "network"
providers), most of your medical bills are covered.
When you go to doctors in the PPO, you present
a card and do not have to fill out forms. Usually
there is a small copayment for each visit. For
some services, you may have to pay a deductible
and coinsurance.
As with an HMO, a PPO requires that you choose
a primary care doctor to monitor your health
care. Most PPOs cover preventive care. This
usually includes visits to the doctor, well-baby
care, immunizations, and mammograms.
In a PPO, you can use doctors who are not part
of the plan and still receive some coverage.
At these times, you will pay a larger portion
of the bill yourself (and also fill out the
claims forms). Some people like this option
because even if their doctor is not a part of
the network, it means they don't have to change
doctors to join a PPO. |
| Questions to Ask About a PPO |
- Are there many doctors to
choose from? Who are the doctors in the
PPO network? Where are they located? Which
ones are accepting new patients? How are
referrals to specialists handled?
- What hospitals are available
through the PPO? Where is the nearest hospital
in the PPO network? What arrangements does
the PPO have for handling emergency care?
- What services are covered?
What preventive services are offered? Are
there limits on medical tests, out-of-hospital
care, mental health care, prescription drugs,
or other services that are important to
you?
- What will the PPO plan
cost? How much is the premium? Is there
a per-visit cost for seeing PPO doctors
or other types of co-payments for services?
What is the difference in cost between using
doctors in the PPO network and those outside
it? What is the deductible and coinsurance
rate for care outside of the PPO? Is there
a limit to the maximum you would pay out
of pocket?
|
| |
| Point-of-Service (POS) Plan |
Many HMOs offer plan members
the option to self direct care, as one would
under an indemnity or PPO plan, rather than
get referrals from primary care physicians.
An HMO with this opt-out provision is known
as a point-of-service (POS) plan. How the plan
functions (i.e., like an HMO or like an indemnity
plan) depends on whether individual plan members
use their primary care physician or self direct
their care at the "point of service."
To illustrate this point, this is how these
plans typically work. When medical care is needed,
the individual plan member essentially has up
to two or three choices, depending on the particular
health plan. The plan member can choose to go
through his or her primary care physician, in
which case services will be covered under HMO
guidelines (i.e., usually a co-payment will
be required). Alternatively, the plan member
can access care through a PPO provider and the
services will be covered under in-network PPO
rules (i.e., usually a co-payment and coinsurance
will be required). Lastly, if the plan member
chooses to obtain services from a provider outside
of the HMO and PPO networks, the services will
be reimbursed according to out-of-network rules
(i.e., usually a co-payment and higher coinsurance
charge will be required). Because people who
belong to POS plans are responsible for deciding
how to access care within the various options,
it is important that they understand the financial
implications of these choices. |
|
| |
| Where Can I Obtain Health Insurance Coverage? |
| Group Insurance |
Most Americans get health insurance
through their jobs or are covered because a
family member has insurance at work. This is
called group insurance. Group insurance is generally
the least expensive kind. In many cases, the
employer pays part or all of the cost.
Some employers offer only one health insurance
plan. Some offer a choice of plans: a fee-for-service
plan, a health maintenance organization (HMO),
or a preferred provider organization (PPO),
for example. Employers with 25 or more workers
are required by Federal law to offer employees
the chance to enroll in an HMO.
What happens if you or your family member leaves
the job? You will lose your employer- supported
group coverage. It may be possible to keep the
same policy, but you will have to pay for it
yourself. This will certainly cost you more
than group coverage for the same, or less, protection.
A Federal law makes it possible for most people
to continue their group health coverage for
a period of time. Called COBRA (for the Consolidated
Omnibus Budget Reconciliation Act of 1985),
the law requires that if you work for a business
of 20 or more employees and leave your job or
are laid off, you can continue to get health
coverage for at least 18 months. You will be
charged a higher premium than when you were
working.
You also will be able to get insurance under
COBRA if your spouse was covered but now you
are widowed or divorced. If you were covered
under your parents' group plan while you were
in school, you also can continue in the plan
for up to 18 months under COBRA until you find
a job that offers you your own health insurance.
Not all employers offer health insurance. You
might find this to be the case with your job,
especially if you work for a small business
or work part-time. If your employer does not
offer health insurance, you might be able to
get group insurance through membership in a
labor union, professional association, club,
or other organization. Many organizations offer
health insurance plans to members. |
| |
| Individual Insurance |
If your employer does not offer
group insurance, or if the insurance offered
is very limited, you can buy an individual policy.
You can get fee-for-service, HMO, or PPO protection.
But you should compare your options and shop
carefully because coverage and costs vary from
company to company. Individual plans may not
offer benefits as broad as those in group plans.
If you get a non-cancelable policy (also called
a guaranteed renewable policy), then you will
receive individual insurance under that policy
as long as you keep paying the monthly premium.
The insurance company can raise the cost, but
cannot cancel your coverage. Many companies
now offer a conditionally renewable policy.
This means that the insurance company can cancel
all policies like yours, not just yours. This
protects you from being singled out. But it
doesn't protect you from losing coverage.
Before you buy any health insurance policy,
make sure you know what it will pay for...and
what it won't. To find out about individual
health insurance plans, you can call insurance
companies, HMOs, and PPOs in your community,
or speak to your insurance agent. |
| |
| Tips when shopping for individual
insurance: |
- Shop carefully. Policies
differ widely in coverage and cost. Contact
different insurance companies, or ask your
agent to show you policies from several
insurers so you can compare them.
- Make sure the policy protects
you from large medical costs.
- Read and understand the policy.
Make sure it provides the kind of coverage
that's right for you. You don't want unpleasant
surprises when you're sick or in the hospital.
- Check to see that the policy
states: the date that the policy will begin
paying (some have a waiting period before
coverage begins), and what is covered or
excluded from coverage.
- Make sure there is a "free
look" clause. Most companies give you at
least 10 days to look over your policy after
you receive it. If you decide it is not
for you, you can return it and have your
premium refunded.
- Beware of single disease
insurance policies. There are some polices
that offer protection for only one disease,
such as cancer. If you already have health
insurance, your regular plan probably already
provides all the coverage you need. Check
to see what protection you have before buying
any more insurance.
|
| |
| Medicare |
Medicare is the Federal health
insurance program for Americans age 65 and older
and for certain disabled Americans. If you are
eligible for Social Security or Railroad Retirement
benefits and are age 65, you and your spouse
automatically qualify for Medicare.
Medicare has two parts: hospital insurance,
known as Part A, and supplementary medical insurance,
known as Part B, which provides payments for
doctors and related services and supplies ordered
by the doctor. If you are eligible for Medicare,
Part A is free, but you must pay a premium for
Part B.
Medicare will pay for many of your health care
expenses, but not all of them. In particular,
Medicare does not cover most nursing home care,
long-term care services in the home, or prescription
drugs. There are also special rules on when
Medicare pays your bills that apply if you have
employer group health insurance coverage through
your own job or the employment of a spouse.
Medicare usually operates on a fee-for-service
basis. HMOs and similar forms of prepaid health
care plans are now available to Medicare enrollees
in some locations.
The best source of information on the Medicare
program is the Medicare Handbook. This booklet
explains how the Medicare program works and
what your benefits are. To order a free copy,
write to: Health Care Financing Administration,
Publications, N1-26-27, 7500 Security Blvd.,
Baltimore, MD 21244-1850. You also can contact
your local Social Security office for information.
Some people who are covered by Medicare buy
private insurance, called "Medigap" policies,
to pay the medical bills that Medicare doesn't
cover. Some Medigap policies cover Medicare's
deductibles; most pay the coinsurance amount.
Some also pay for health services not covered
by Medicare. There are 10 standard plans from
which you can choose. (Some States may have
fewer than 10.) If you buy a Medigap policy,
make sure you do not purchase more than one.
You need to shop carefully before deciding on
the best policy to fit your needs. You may get
another booklet, Guide to Health Insurance for
People with Medicare, to help you in making
the right choice. To order a free copy, write
to: Health Care Financing Administration, Publications,
N1-26-27, 7500 Security Blvd., Baltimore, MD
21244-1850.
Another good source of information on the same
topic is The Consumer's Guide to Medicare Supplement
Insurance. To order a free copy, write to: Health
Insurance Association of America, 555 13th St.,
N.W., Suite 600 East, Washington, D.C. 20004. |
| |
| Medicaid |
| Medicaid provides health care
coverage for some low-income people who cannot
afford it. This includes people who are eligible
because they are aged, blind, or disabled or
certain people in families with dependent children.
Medicaid is a Federal program that is operated
by the States, and each State decides who is
eligible and the scope of health services offered.
|
|
| |
| Business Insurance |
| What
is a buy/sell agreement? |
| A Buy/sell Agreement is a contractual
agreement that provides for the continuation
of a business in the event of the death or disability
of a sole proprietor, partner or shareholder.
An agreement may stipulate that, upon the death
of a shareholder or partner of a company, the
company or other partners buy back the deceased's
interest in the business. Life insurance is
commonly used to fund buy/sell agreements because
it provides both liquidity and tax advantages
in funding the transaction. |
| The following are important reasons
to use a funded buy/sell agreement: |
- Liquidity - A funded buy/sell
agreement creates a market instantly for
the deceaseds share of the business. Otherwise,
if a funded buy/sell agreement were not
in place, the purchase of the deceaseds
stake in the business would have to come
out of the companys working capital (if
there was enough to fund the purchase).
In addition, if an outside party were to
purchase the deceaseds share, the timing
of the transaction could result in a lower
valuation of the company because of the
death of a key owner and the fact that the
deceaseds family wants to sell in a potentially
soft market.
- Transition of Business -
A funded buy/sell agreement assists in the
efficient preservation and transition of
the control and management of the business.
- Estate Planning - A funded
buy/sell agreement can provide cash for
potential estate taxes and settlement costs
and establish a valuation of the deceaseds
business interest for estate tax purposes.
- Cost - a funded buy/sell
agreement funded with life insurance can
be inexpensive (the cost for the purchase
of a business is essentially the premiums
paid for the life insurance policy).
|
| Life insurance provides a simple
way to administer a funding vehicle for the
purchase of the deceaseds ownership according
to the terms of the buy/sell agreement. The
business also protects itself from any future
drain on working capital, damage to its credit
position and/or the legal or financial problems
that could arise out of the companys inability
to fund the buy/sell agreement with its own
income |
| How
does a buy/sell agreement funded by life insurance
work? |
| Buy/sell agreements may be set
up in conjunction with Sole Proprietorships,
Partnerships and Corporations. The method for
each is a little different. Below you will find
a general description of the options available
for each type of business. |
| |
| Sole Proprietorship |
| If a sole proprietor has a key
employee that has the desire to purchase the
business in the event of the sole proprietors
death, a buy/sell agreement can facilitate the
key employee's purchase of the deceased's business.
The sole proprietor and the key employee would
enter into a buy/sell agreement, and the key
employee would purchase a life insurance policy
on the life of the sole proprietor. Pursuant
to the buy/sell agreement, upon the death of
the sole proprietor, the key employee uses the
death benefit to purchase the sole proprietors
business from his estate. |
| |
| Partnership |
| Cross-Purchase Method |
| The Cross Purchase Method of
entering into a buy/sell agreement works best
if there are a small group of partners (preferably
two). The partners enter into a buy/sell agreement
and each partner buys a life insurance policy
on each of the other partners lives. Pursuant
to the agreement, upon the death of one of the
partners, the surviving partners use the death
benefit from the above-mentioned policies to
buy the deceased partner's business interest
from his or her estate. The surviving partners
then own all of the partnership while the deceased
partners estate receives the funds from the
sale of the deceased partners share of the partnership. |
| Entity
Method |
| The Entity Method of entering
into a buy/sell agreement offers the advantage
of simplicity over the Cross-Purchase Method
if there are more than two partners or if there
is a likelihood of more partners joining the
business later. In this scenario, the partnership
and each partner enter into a buy/sell agreement.
The partnership buys a life insurance policy
on each of the partners lives. Pursuant to the
buy/sell agreement, upon the death of one of
the partners, the partnership uses the death
benefit from the above-mentioned policy to purchase
the deceased partners business interest from
his or her estate. The surviving partners then
own all of the partnership while the deceased
partners estate receives the funds from the
sale of the deceased partners share of the partnership. |
| |
| Corporation |
| Cross-Purchase Method |
| The Cross-Purchase Method of
entering into a buy/sell agreement works best
if there are a small group of shareholders (preferably
two). The shareholders enter into a buy/sell
agreement and each shareholder buys a life insurance
policy on each of the other shareholders lives.
Pursuant to the buy/sell agreement, upon the
death of one of the shareholders, the surviving
shareholders use the death benefit from the
above-mentioned policies to buy the deceaseds
shareholders business interest from his or her
estate. The surviving shareholders will own
all of the outstanding corporate stock while
the deceased shareholders estate receives the
funds from the sale of the deceased shareholders
stocks. |
| Stock
Redemption Method |
| The Stock Redemption Method of
entering into a buy/sell agreement offers the
advantage of simplicity over the Cross-Purchase
Method if the corporation has more than two
shareholders or if there is a likelihood that
additional shareholders will join the business
later. In this scenario, the corporation and
each shareholder enter into a buy/sell agreement,
and the corporation buys a life insurance policy
on each of the shareholders lives. Pursuant
to the buy/sell agreement, upon the death of
one of the shareholders, the corporation uses
the death benefit from the above-mentioned policy
to purchase the deceaseds shareholders business
interest from his or her estate. The surviving
shareholders then own all the outstanding corporate
stock while the deceased shareholders estate
receives the funds from the sale of the deceased
shareholders stock |
|
| |
| What is Key Person Life Insurance? |
| Maybe your business is operated
primarily by one person or maybe your company
is run by a small team of executives whose expertise
is the lifeline of your business. The premature
death of a key person could signal the premature
death of the business. With a Keyperson Life
Insurance Policy, a business can increase the
chances of survival if it were to lose a key
member of the organization. |
- cover business debt
- leave working capital for
a surviving partner(s) to continue the business
- identify and hire a replacement
for the key person
- provide cash for the business
in case there is a major revenue shortfall
because of the loss of the key person
|
| |
| How do you set up a Key Person Life Insurance Policy? |
The first factor to consider
in setting up a Keyperson Life Insurance Policy
is to determine how much death benefit is needed.
The minimum usually considered is one times
the key persons annual income, but other factors
need to be considered. What if the business
relationships of this person drive half of the
companys revenues? How difficult and costly
will finding a replacement be? Are there business
debts that would place financial hardship on
the company?
Once the death benefit amount has been determined,
the business would purchase the policy on the
key person. The key person would be the insured
and the business would be the owner, payor and
beneficiary of the policy. Permanent or term
life insurance can be used as a key person policy
depending on the needs of the business and how
much they are willing to spend. |
|
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