Frequently Asked Questions What are the qualifications for a BGO (Business Group of One)? The group must have been in business in Colorado for at least one year. The group must show enough documentable income to cover the annual premium. The group must be filing a Schedule C or a K-1 (if an LLC). If the group is very healthy (no medical history), many companies will allow the group to enroll at any time.
If there is some history (anything as simple as an ongoing prescription), insurance companies may make the group wait to enroll on your birthday. If the health history of the group is deemed by the insurance company to be more serious, the insurance company must still issue you a plan, but they will only allow the group to choose between two “state mandated" plans.

What information would you need for running my quote?

You may click on the following links for a PDF file that can be printed and faxed or emailed to us. When your quote is ready, we will contact you and set up an appointment.

Employee Group Benefit - Reguest Online or Download the PDF Census Form

Individual Coverage - Request Online or Download the PDF Quote Request Form

What does COBRA mean to me? What is it? How does it affect me?
COBRA applies to employers with an average of 20 or more employees. COBRA allows for employees to remain on the ex-employer’s medical and dental plans for up to 18 months (36 months under certain circumstances) at the employee’s expense.

What are the limits for coinsurance and how are they determined?

Coinsurance amounts are set when the employer decides on the plan they will offer. Each plan offered by an insurance company has its own coinsurance amount.

If I am covered by two health plans, how does “Coordination of Benefits" work?

By law, insurance companies need to know if you have coverage elsewhere (this question is asked on all insurance applications). If you are covered by two different health plans, the one offered by your employer pays first and is the “Primary" plan. The balance can then be sent to the second plan for payment.

What is ERISA and what does it mean to me? How does it affect me?

There are so many ERISA laws that may or may not apply to individual employers. If you have questions regarding ERISA, you need to consult legal council. There are many lawyers who specialize in this area.

Are “Exclusions and Limitations" different with different plans? What are some of the conditions I need to be aware of?

Each insurance company has different limitations and exclusions for both individual and group plans. Check your policy certificate for those specific to your plan.

What are the advantages/disadvantages of Formulary Drugs vs. Non-formulary vs. Generic drugs? Who makes the decisions about when to go with a Formulary/Non-formulary/Generic drug? If the decision is up to the subscribers, is there anything else the subscriber should be aware of when making a decision on this issue?

Insurance companies are getting away from defining drugs as generic/formulary/non-formulary and defining them as Tier 1,2,3 & 4 drugs. Thus allowing for some higher costing generic drugs to be elevated to a Tier 2 while the lower costing Formulary drugs can be put into the Tier 1 category. Tiers 2-4 having a higher copay than Tier 1.

As far as who makes the decisions about which drug to take, the subscriber and their doctor should make the decision. The subscriber will want to discuss the best options with their doctor that they have within the framework of their plan. For a more detailed description of the categories, please see below.

Generic drugs
Generic equivalents are medications that have the same active ingredients, and provide the same clinical benefits, as their brand-name counterparts. Generic equivalents become available when a brand-name drug patent expires. They may look different than their counterpart brand-name drugs in size, shape or color, but they meet the same U.S. Food and Drug Administration standards for safety, purity and potency.

Generic substitution
The practice of dispensing a generic equivalent instead of the brand counterpart. Substitutions can only occur when a generic equivalent is available, when the substitution is allowed by law, and when the physician has not marked the prescription "dispense as written."

Formulary
Formulary is a list of prescription drugs that have been selected and approved by the insurance company for their safety, quality, and cost effectiveness.

Non-Formulary products
Products not included on the insurance company’s Prescription Formulary.

How and when is the “Lifetime Maximum" determined?

Each plan has it’s own “Lifetime Maximum" and is determined by the insurance company.

How are “Usual and Reasonable" charges determined? How does the subscriber know what is “Usual and Reasonable" Is this amount divulged to the subscriber on their “Explanation of Benefits"?

This information is determined by doctors, hospitals and medical professionals and is not “public" information. In reality, they look at what 8 of 10 others are charging for the same procedure and that is what they will charge on average. It is not on your “EOB" (Explanation of Benefits) statements. Your EOB usually shows the maximum allowable payment for each charge.

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Insurance 101

Following are some of the terms you may hear when dealing with your insurance. These are provided to help you better understand your insurance. If you have any questions that are not listed here, please feel free to ask Keith from HERE.

Active Employee - is an Employee who is on the regular payroll of the Employer and who is scheduled to perform the duties of his or her job with the Employer on a full-time basis. (Full-time status is determined by the Employer)

Calendar Year - means January 1st through December 31st of the same year.

COBRA - the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.

Coinsurance - A specified percentage of the cost of treatment the insured is required to pay for all covered medical expenses remaining after the deductible has been met.

Coordination of Benefits - means when a Covered Person has two or more insurance plans, the plans will coordinate benefits when a claim is received.

Copay - A fixed dollar amount you pay at the time services are rendered. Typical copays are for office visits, prescriptions, or hospitalizations.

Covered Person - is an Employee or Dependent who is covered under the Plan.

Deductible - The portion of your health care that you pay before insurance starts covering it. Typically, the higher the deductible, the lower the premiums.

Employee - is a person who is an Active, regular Employee, regularly scheduled to work for the Employer in an Employee/Employer relationship.

Employee Contribution - is the amount of premium the employer requires the employee to pay towards his or her health insurance.

Enrollment Date - is the first day of coverage or, if there is a waiting period, the first day of the waiting period.

Enrollment or Eligibility Period - The time during which a new group member may first enroll for group insurance coverage.

ERISA - Employee Retirement Income Security Act of 1974, as amended.

Exclusions and Limitations - Conditions, situations and services not covered by the health plan.

Formulary Drugs - Formulary drugs generally have a lower copay. A formulary drug is one that has been thoroughly reviewed by a team of expert pharmacists and physicians; these drugs have been identified as safe, effective and beneficial to members for treating medical conditions. When deciding which drugs are equally safe and effective, the formulary team also considers the relative costs of medications. These savings are then passed on to you through lower premiums.

Generic Drug - A Prescription Drug, which has the equivalent use and metabolic disintegration of the brand name drug.

HDHP- High Deductible Health Plan (HDHP), usually coupled with a qualified HSA (Health Savings Account). 

Health Insurance Portability and Accountability Act of 1996 (HIPAA) - Under this federal law (known as HIPAA), group health plans cannot deny coverage based solely on an individual's health status. This law also gives employees who change or lose their jobs better access to health coverage, guarantees renewability and availability to certain employees and limits exclusions for pre-existing conditions.

Health Maintenance Organization (HMO) - HMOs require that you only utilize physicians within their network, often going so far as to require you to choose a primary care physician who directs most courses of your treatment. Referrals are required from your PCP (Primary Care Physician) to see a specialist.

HRA- Health Reimbursement Account (HRA), plan set up by the employer to help pay eligible medical expenses.

HSA/Health Saving Account-Health Savings Accounts are tax-qualified bank accounts that are coupled with high deductible plans, used not only for medical expenses but other expenses such as Dental  X-rays and eyeglasses (see list of Eligible Medical Expense) See also the IRS Publication 502 – Qualified Medical and Dental Expenses.

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Injury - an accidental physical injury caused by unexpected external means.

Intensive Care Unit - is defined as a separate, clearly designated area which is maintained within a Hospital solely for the care and treatment of patients who are critically ill.

Late Enrollee - a Plan Participant who enrolls under the Plan other than during the first 31-day period in which the individual is eligible to enroll under the Plan or during a Special Enrollment Period.

Legal Guardian - a person recognized by a court of law as having the duty of taking care of the person and managing the property and rights of a minor child.

Lifetime Maximum - The maximum amount of money a plan will pay towards healthcare services over the course of the insured's lifetime.

MSA - benefits - The newest choice in health insurance for the self-employed, Medical Savings Accounts (MSAs) allow you to build up a tax-free savings account to pay for routine medical expenses.

Medically Necessary - care and treatment is recommended or approved by a Physician; is consistent with the patient's condition or accepted standards of good medical practice; is medically proven to be effective treatment of the condition; is not performed mainly for the convenience of the patient or provider of medical services; is not conducted for research purposes; and is the most appropriate level of services which can be safely provided to the patient.

All of these criteria must be met; merely because a Physician recommends or approves certain care does not mean that it is Medically Necessary.

The Plan Administrator has the discretionary authority to decide whether care or treatment is Medically Necessary.

Network - A group of doctors, hospitals and other health-care providers contracting with a health plan, usually to provide care at special rates and to handle paperwork with the health plan.

Non-formulary Drugs - Non-formulary drugs often require a higher copayment. Non-formulary drugs are those that have not yet been reviewed or have been denied formulary status, typically because they offer no extra benefit over the drugs already on a plan's formulary list.

Outpatient Care - is treatment, including services, supplies and medicines provided and used at a Hospital under the direction of a Physician to a person not admitted as a registered bed patient; or services rendered in a Physician's office, laboratory or X-ray facility, an Ambulatory Surgical Center, or the patient's home.

Point-of-Service Plan - An HMO plan that also incorporates an indemnity plan option allowing members to obtain medical care from providers outside of the HMO network at a reduced benefit and at greater out-of-pocket expense.

Physician - means a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Podiatry (D.P.M.), Doctor of Chiropractic (D.C.), Audiologist, Certified Nurse Anesthetist, Licensed Professional Counselor. Licensed Professional Physical Therapist, Midwife, Occupational Therapist, Optometrist (O.D.), Physiotherapist, Psychiatrist, Psychologist (PhD.), Speech Language Pathologist and any other practitioner of the healing arts who is licensed and regulated by a state or federal agency and is acting within the scope of his or her license.

Plan Administrator - is the employer, also known as the Plan Sponsor.

Plan Participant - is any Employee or Dependent who is covered under the Plan.

Plan Year - is the 12-month period beginning on either the effective date of the Plan or on the day following the end of the first Plan Year which is a short Plan Year.

Pre-Existing Condition - (1) According to most individual health insurance policies, an injury that occurred or a sickness that first appeared or manifested itself before the policy was issued. (2) According to most group health insurance policies, a condition for which an employee received medical care prior to the effective date of coverage.

Preferred Provider Organization (PPO) - An organization where providers are under contract with an insurance company or health plan to provide care at a discounted or negotiated rate. Typically, you can see any doctor in the PPO network without requiring special approval, and you usually do not need to choose a primary care physician. Most PPOs will also allow you to seek care outside of the PPO network; however, the benefits are usually reduced and the insured has a greater out-of-pocket expense.

Primary Care Physician (PCP) - A general or family practitioner who serves as the insured's personal physician and first contact with a managed care system. The PCP will usually direct the course of your treatment and/or refer you to other doctors and/or specialists in the network.

Short-Term Disability - This type of coverage pays a percentage of your salary if you become temporarily disabled, meaning that you are not able to work for a short period of time due to sickness or injury (excluding on-the-job injuries, which are covered by workers compensation). The per-week amount is usually 50, 60 or 66 2/3 percent of your weekly salary, and lasts for a period of time specified by the plan.

Usual and Reasonable Charge - The maximum dollar amount of a covered expense that is considered eligible for reimbursement under a major medical policy.

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