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Healthier And WISER

This checklist addresses some of the main health care coverage issues women encounter at different stages of their lives.

Many people who have health insurance obtain it through an employer, however, there may be times in your life when you are without coverage, facing coverage choices or grappling with retirement health issues. This checklist addresses some of the main health care coverage issues women encounter at different stages of their lives. This is a series of nine questions and answers based on health care coverage issues women encounter at various stages of their lives, along with answers providing direction. It will point you in the direction of where to go to find more information. It is not intended as legal advice.

The stages include:

• For those without coverage;
• On the job;
• You and your family; and
• After retirement.

For Those Without Coverage

1. If you, your husband, or both, are working, but your employers do not offer health care coverage, are there affordable coverage options for you?

• You may be able to get group coverage—and more favorable rates—if you are a member of an organization that offers group health care coverage. This could be a fraternal organization or a professional society, for example. You may also be able to buy health insurance on your own, but it may be quite expensive. Be sure to obtain bids from several different insurance companies and local managed care organizations.
• High-deductible plans often offer more affordable monthly premiums and take care of major medical expenses such as hospitalizations, but not routine care. However, you would have to cover expenses that arise before you meet the deductible out of your own pocket.
• If you can’t enroll in a group plan and have a chronic condition that prevents you from buying an individual plan, you can check with your state’s insurance department to see if you might qualify for plans available for people in your circumstances. 
• If you have a high deductible health insurance plan, you might also consider opening a Health Savings Account (HSA). The HSA is a special tax-advantaged savings account that is used for health care needs. You can deposit before taxes money into HSA accounts and use the tax-free money to pay medical expenses and insurance premiums. This option may be right for you if you have the money to set aside in an HSA, if you can use additional tax deductions, and if you have trouble finding traditional health care coverage that you can afford. A word of caution: for many people, the tax savings of an HSA will be lower than the out-of-pocket costs of a higher deductible health insurance plan. Talk to a bank or credit union that sponsors HSA plans for more details.

2. If you work part-time, can you qualify for health care coverage from your employer if you increase your hours?

• Employers don’t have to offer health care plans, and they are not required to cover everybody they employ. Most companies that offer health benefits require that you work a certain number of hours per year to qualify for health benefits, so it is worth finding out if changing your work schedule would make you eligible for benefits. It is often a smart financial move to increase your hours at your current job, or even change jobs if that is an option, in order to obtain health care coverage for your family.

3. If you are not working, or have a low annual income, what are your options?

• If you have lost your insurance due to loss of a job or a spouse, look into COBRA coverage. COBRA is a law that gives you the right to buy coverage in a workplace plan if you are no longer eligible to be covered under the plan as an employee or a dependent of one. You have 60 days to sign up for it through your previous employer or your spouse’s previous employer. Once you sign up for COBRA coverage, you will be allowed to stay in the plan for a specified time period, although you will be required to pay the full premium for coverage. Ask the former employer for more details about the options and benefits.
• Medicaid provides health coverage for low-income individuals and families. Low and moderate-income children can often be covered through the State Children’s Health Insurance program (SCHIP) and some state programs are now covering parents and childless adults as well. Call your state Medicaid office for more information.

4. If you don't have health care coverage, can you negotiate fees with providers or do you have to pay whatever the doctor or hospital charges?

• If you don’t have coverage, always try to negotiate a price and/or a payment schedule, although providers have no obligation to accept your offer. You might offer to pay the provider whatever an insurance plan would have paid for your treatment, which would generally be lower than the provider’s “sticker price”.

On the Job

If both you and your husband are offered health care coverage through your employers, should you each enroll in your own plan, both enroll in one plan, or both enroll in both plans?

• What you should do depends on what each of your plans says. Ask for the Summary Plan Descriptions for each plan (the documents should have this title) and read about family coverage and coordination of benefits.
• Your plans may require that each of you be enrolled in your own employer’s plan as your primary plan. In that case, you could still enroll in your spouse’s plan, but your spouse’s plan would only cover expenses your own plan does not. You may also have a choice of choosing one plan and enrolling in family coverage. Many times, it is more cost effective for an entire family to be enrolled in one plan, and face only one deductible and set of premiums.

You and Your Family

1. What are your rights to health care coverage through your husband’s job if you and your husband separate or divorce? If your husband dies? What are your children’s or stepchildren’s rights in these cases?

• In general, a divorce or the death of the spouse with the plan qualifies you under COBRA to remain covered under the plan for up to 36 months, but your own circumstances could lengthen or shorten this period. Children covered under the plan may be able to retain coverage even longer in the event of a divorce. If you are getting a divorce or need to enforce child support, you should also ask your attorney about filing a qualified medical support order (QMSO). A QMSO can be used to require employer-sponsored group health plans to extend health care coverage to the children of a parent/employee who is divorced, separated, or never married when ordered to do so by state authorities.

2. Can you or your family qualify for health care coverage through the military if one of you served and was honorably discharged even though s/he did not serve a full 20-year career?

• Depending on your family’s income, you and your family may be eligible for health care coverage through the military, even if the one who served did not serve a full career. You should contact your local Veteran’s Affairs office if you think you might qualify; their phone number and address is in your telephone directory in the federal government section, or go to www1.va.gov/directory/guide/map.asp to find the office nearest you.

3. Why is it important to stay enrolled in some kind of health plan if you have a chronic or pre-existing condition?

• If you have continuous coverage, including COBRA coverage, you will not have to meet required waiting periods to get treatment for pre-existing conditions under your next health plan. Your old plan should issue you a certificate of coverage, showing that you were continually covered prior to enrolling in the new plan.

After Retirement

If you are enrolled in Medicare and cannot afford to pay the out-of-pocket costs Medicare does not cover, is there any other assistance for you?

There are several types of assistance that may fit your circumstances:

• There are state programs for individuals with incomes below or near federal poverty limits. For those at or below the poverty level, with limited resources, the Qualified Medicare Beneficiary Program (QMB) will pay your premiums, deductibles and co-payments under Medicare. The Specified Low-Income Medicare Beneficiary Program (SLMB) and the Qualified Individual Program (QI) pay Medicare Part B premiums for those with with limited resources. The income and asset limits vary by program. The programs can save you hundreds, or even thousands, of dollars each year. To see if you qualify, call or visit your state Medicaid office. You can also call 1-800-MEDICARE (1-800-633-4227) and say “Medicaid.”
• • Extrahelp can assist Medicare beneficiaries in paying for prescription drug costs related to Medicare Part D. The SSA estimates Extrahelp to be worth $4,000 a year. You are eligible if your assets are limited to $13,070 for an individual and $26,120 for a couple. In addition, you cannot earn more than $16,755, or $22,695 for a couple. You can apply online at www. socialsecurity.gov/extrahelp.
• You might benefit from a medigap insurance policy - a private insurance policy that pays out-of-pocket medical costs not covered by Medicare. For more information on medigap insurance policies sold in your state, go to http://www.medicare.gov/find-a-plan/questions/medigap-home.aspx. You can also call your state insurance commissioner. Every state offers free insurance counseling to seniors through a program called the SHIP program. Call Medicare at 1-800-Medicare for the nearest SHIP site.
• The National Council on the Aging has an interactive website program, called Benefits Check-Up, that will point you toward an array of state and private programs that can help you with medical costs. Find it on the web at www.benefitscheckup.
• Many localities have Medicare approved Health Maintenance Organizations (HMO), also called Medicare Advantage plans, for seniors. These plans often cover medical expenses not covered by the traditional Medicare fee-for service plan, including prescription drugs, eyeglasses and dental care in some instances. Call 1-800-Medicare for more information.

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