Below
are a
series
of
definitions
of
various
health
insurance
plans
and
programs
available
to
Arizonans.
As
confusing
as they
may be,
we have
tried to
provide
simple
definitions.
Where
relevant,
we have
also
tried to
provide
links
and
additional
frequently
asked
questions
(FAQs)
to help
consumers
understand
these
programs.
COBRA
(Consolidated
Omnibus
Budget
Reconciliation
Act)
Discount
Health
Plans
EPO
(Exclusive
Provider
Organization)
ERISA
(Employee
Retirement
Income
Security
Act)
Evidence-based
Medicine
FMLA
(Family
Medical
Leave
Act)
HIPAA
(Health
Insurance
Portability
and
Accountability
Act)
HMO
(Health
Maintenance
Organization)
HSA
(Health
Savings
Account)
Medicaid
Medicaid
Medicare
Medi-gap
Insurance
MRMIP
(Major
Risk
Medical
Insurance
Program)
POS
(Point
of
Service)
PPO
(Preferred
Provider
Organization)
COBRA
(Consolidated
Omnibus
Budget
Reconciliation
Act)
Have you
recently
left
your
employer?
COBRA allows
former
employees,
retirees,
and
their
dependents
to
temporarily
keep
their
health
coverage
at group
rates.
It is
more
expensive
than
group
insurance.
Why?
When you
are
employed,
your
employer
usually
pays
some or
all of
the premium
for your
health
insurance.
COBRA
participants
pay the
entire
premium
themselves.
It may
be less
expensive
than
individual
coverage,
though.
You can
collect
COBRA
benefits
for up
to 18
months
which
may be
extended
to 36
months
under
certain
circumstances.
If your
employer
has 20
or more
employees
they
must
follow
COBRA
rules.
COBRA
follows
a
"qualifying
event,"
like a
termination
(other
than for
gross
misconduct),
layoff,
or
reduction
in work
hours
(but not
taking
FMLA
leave –
see
"FMLA").
You have
responsibilities
to make
sure
your
COBRA
coverage
goes
into
effect
and
stays in
effect.
You must
decide
to
accept
or
reject
COBRA
during a
certain
time
period
(usually
60 days
away
notification
from
employer).
Your
former
employer's
plan
administrator
must
mail you
the
COBRA
information
and
forms
within
14 days
after
receiving
notification
from
your
former
employer
of the
qualifying
event.
If you
do not
ask for
COBRA
coverage
before
the
deadline
you may
lose the
right to
COBRA
coverage.
You must
also be
sure to
pay your
monthly
premiums
or you
can lose
your
coverage.
Once you
have
exhausted
your
COBRA
benefits,
you may
be
entitled
to
obtain
an
extension
of
coverage
under
CalCOBRA.
When all
COBRA/CalCOBRA
extensions
are
exhausted,
you can
obtain
individual
health
insurance
under
HIPAA
(see
"HIPAA").
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Discount
Health
Plans
Discount
health
plans
are not
insurance.
They are
simply
organizations
that
arrange
discounts
for
medical
services,
often
issuing
a card
to you
for that
purpose.
Note
that
providers
are
*not*
obligated
to
accept
the
discount
plan, so
not all
providers
participate.
Be very
careful
when
deciding
to
purchase
a
discount
health
plan.
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EPO
(Exclusive
Provider
Organization)
In an
EPO you
must use
the
providers
who
belong
to the
EPO or
your
expenses
will not
be
covered.
In other
words,
you
cannot
go
"outside"
the
network
for
medical
care.
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ERISA
(Employee
Retirement
Income
Security
Act)
The
Employee
Retirement
Income
Security
Act is a
Federal
law that
sets
minimum
standards
for
pension
plans
and
self-insured
health
plans in
private
industry.
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Evidence-Based
Medicine
In
evidence-based
medicine,
treatment
success
is
measured
by a
careful
study of
the
outcome,
using
both the
clinical
expertise
of the
provider,
as well
as the
most
up-to-date
research
available.
EBM
encourages
the use
of
consistent,
efficient,
scientific
guidelines
for
medical
treatment
decisions.
EBM
protocols
may be
especially
useful
in
preventive
care and
management
of
chronic
conditions
such as
asthma
and
diabetes.
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FMLA
(Family
Medical
Leave
Act)
If your
employer
has 50
or more
employees,
you may
be
eligible
for
FMLA.
The FMLA
guarantees
employees
up to 12
workweeks
of
unpaid
leave
during
any 12
month
period
for
reasons
like the
birth of
a child
("maternity
leave"),
taking
care of
sick
immediate
family
members,
or for
your own
serious
health
condition.
In order
to
obtain
FMLA
leave,
you must
notify
your
employer
30 days
in
advance
of
taking
the
leave.
If it
is an
emergency,
you must
notify
your
employer
as soon
as
possible.
You must
also be
an
employee
of your
current
employer
for at
least 12
months
before
taking
FMLA
leave.
While
taking
FMLA
leave,
your
employer
must
continue
the same
group
health
insurance
coverage
for you
as for
similar
other
employees.
If you
already
pay a
premium,
though,
you must
continue
to pay
it.
Your
employer
can help
you to
make
arrangements
to do
so.
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HIPAA
(Health
Insurance
Portability
and
Accountability
Act)
HIPAA is
a
Federal
law that
does
three
things:
1) it
makes it
easier
to take
your
health
information
with you
when you
change
employers,
2) it
sets
very
strict
rules
about
the
privacy
of your
medical
records,
and
3) it
gives
you the
right to
purchase
individual
health
insurance
after
you've
used up
your
COBRA
benefits
(see
"COBRA").
Before
HIPAA it
was
often
hard to
move
your
medical
information
from one
insurer
to
another,
and
there
were few
safeguards
for your
privacy.
It was
also
very
difficult
to
obtain
insurance
after
COBRA
benefits
ran
out.
HIPAA
improved
these
shortcomings.
If you
have
been
covered
by
health
insurance
including
COBRA
and have
exhausted
all
COBRA/CalCOBRA
benefits
with no
break
longer
than 63
days,
HIPAA
gives
you the
right to
buy
individual
health
coverage
with few
or no
limits
on
pre-existing
conditions.
You may
visit
the
U.S.
Department
of
Health
and
Human
Services
provides
additional
information
related
to
HIPAA.
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HMO
(Health
Maintenance
Organization)
An HMO
is a
collection
of
hospitals,
doctors,
and
other
health
services
all
organized
under
one
network.
By
managing
care and
contracting
with the
providers,
HMOs
keep
costs
down
while
providing
a full
range of
health
services.
You
usually
pay only
small
co-pays
when
using
services,
no
matter
how many
or what
kind of
services
you
use. In
return,
though,
you must
usually
use the
hospital(s),
doctors,
and
other
health
providers
in the
HMO's
network.
In an
HMO, you
select a
primary
care
physician.
If you
need a
specialist,
the
primary
care
physician
must
first
refer
you to
that
specialist
before
you can
see
them.
HMOs in
Arizona
are
regulated
by
Department
of
Insurance
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HSA
(Health
Savings
Account)
In an
HSA, you
contribute
money to
a
special
bank
account
to be
used for
medical
bills.
You get
a
Federal
tax
deduction
on the
money
you
contribute
to your
HSA, and
if you
use the
money
for
medical
expenses,
you pay
no
Federal
tax or
penalty
on it.
The HSA
account
can also
earn
Federal
tax-free
interest.
Note:
there is
no
Arizona
tax
exemption
for your
HSA
contribution,
or for
the
interest
the
account
earns.
HSA's
always
go along
with a
high-deductible
health
insurance
plan --
a $1,500
deductible,
for
example.
This
means
that if
you need
medical
treatment,
you must
first
pay the
deductible,
which
you can
do with
money
from the HSA.
There
are
limits
on how
much you
can
contribute
each
year.
In 2006
you can
contribute
up to
$2,700
per year
for
yourself
(with a
$3,000
deductible
plan),
or
$5,450
per year
for
yourself
and your
family
(with a
$6,000
deductible
plan).
HSA's
"roll-over,"
that
is:
money
you
saved
doesn't
disappear
at the
end of
the year
if you
haven't
used
it. You
simply
continue
contributing
to the
HSA.
There is
no limit
to how
much you
can have
saved in
your
HSA.
The HSA
is also
"portable,"
so you
can move
or
change
jobs and
take the
HSA with
you.
Some
employers
may also
make
contributions
to your
HSA for
you as a
job
benefit.
Who is
eligible
for an
HSA?
Once on
Medicare,
you can
not
obtain a
new HSA. If
you
already
had one
before
joining
Medicare,
however,
you can
keep
that HSA
and use
it, but
you can
not
continue
contributing
to it.
You can
be
eligible
for an
HSA even
if you
have
already
have a
high-deductible
health
plan,
but not
if you
already
have
traditional
health
insurance.
You can
also
still be
eligible
if you
have
disease-specific
insurance
(like a
plan to
cover
just
your
diabetes).
HSA
money
can be
used for
preventive
medical
services
and
drugs
(both
prescription
and
over-the-counter)
without
Federal
tax or
penalty.
You can
use
money
from
your HSA
for
non-medical
expenses,
but
you'll
usually
have to
pay a
tax and
a
penalty.
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Medicare
A
Federal
program
that
mainly
insures
the
elderly
and
disabled
people.
There
are four
parts to
Medicare.
Part A
and B
comprise
the
original
fee-for-service
Medicare
plan.
Part "A"
covers
hospitalization.
Part "B"
covers
doctors'
and
other
outpatient
services.
Part "C"
also
known as
Medicare
Advantage,
is
Medicare
offered
through
a
network
of
providers
such as
HMO
(Health
Maintenance
Organization)
or PPO
(Preferred
Provider
Organization).
Part "D"
covers
prescription
drugs.
You can
also pay
for
private
supplemental
programs
to give
you more
coverage
than
Medicare
offers
(see
"Medi-gap
insurance").
Medi-gap
policies
exist
for many
health
care
services,
but not
prescription
drugs.
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Medi-gap
Insurance
Supplemental
insurance
policies
that you
can
purchase
to pay
for
things
that
Medicare
does
not.
The
insurance
"closes
the gap"
between
what's
paid for
and what
isn't.
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POS
(Point
of
Service)
Plans
that
allow
you to
go
outside
your
network
are
called
POS
plans.
Charges
for
services
outside
your
network
can be
much
higher,
though.
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PPO
(Preferred
Provider
Organization)
In a
PPO,
insurance
companies
contract
with
doctors,
hospitals,
and
other
providers
to form
a
"network."
Depending
upon
your
plan,
you can
sometimes
get
health
care
outside
the
network
(someone
or
someplace
not
included
in the
network)
but you
will
have to
pay
more.
Unlike
an HMO,
you also
have to
pay a
deductible
and
coinsurance.
Also
unlike
an HMO,
you
usually
can see
a
specialist
without
first
being
referred
by your
primary
care
physician,
and you
have
much
more
freedom
in
choosing
a doctor
or
hospital.
PPOs in
Arizona
are
regulated
by the
Arizona
Department
of
Insurance
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