Frequently Asked Questions: Insurance

• Annual Liability Insurance
  • How much does it cost?
    How much does it cost?

    That depends on a lot of things, including what you do and where you are located. The minimum quote for annual general liability is $425, and it just goes up from there. Things that can make it more expensive are: location (some cities and states are more expensive than others because they're "more risky"), number of events, number of spectators, and total payroll.

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  • Is there a deductible?
    Is there a deductible?

    Nope!

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  • What are the limits?
    What are the limits?

    -$1 million per occurrence -$2 or $3 million aggregate (that's the total that the insurance company will pay out) depending on the carrier -$1 million personal and advertising injury -$2 or $3 million products and completed operations depending on the carrier

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  • What can be insured under these policies?
    What can be insured under these policies?

    Almost anything, as long as it's arts-related.

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  • What is annual general liability insurance?
    What is annual general liability insurance?

    It's a year-long policy that covers you against lawsuits that might be brought against you because of damage to rented spaces/locations, injury to spectators or innocent bystanders, etc.

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• Directors and Officers Insurance (D&O)
  • How much does it cost?
    How much does it cost?

    The minimum premium is $650 and it goes up from there.

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  • Is there a deductible?
    Is there a deductible?

    There is a $2500 deductible on certain claims.

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  • What are the limits?
    What are the limits?

    The general aggregate on this insurance is $1,000,000.

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  • What can be insured?
    What can be insured?

    Non-profit arts organizations and fiscally sponsored projects

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  • What is directors' and officers' liability insurance?
    What is directors' and officers' liability insurance?

    Directors' and officers' liability insurance (D&O) offers your individual directors (high-level staff of organizations) and officers (Board members) the protection they need from personal liability and financial loss arising out of wrongful acts committed in their capacity as officers and/or directors. Example: If the Executive Director of an organization runs off with the company's money, this would cover the Board Members and other high-level staff if they were sued. One can also elect to include Employment Practices coverage as well, which covers things like sexual harassment, discrimination, and wrongful termination suits.

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  • What isn't insured?
    What isn't insured?

    For-profit arts organizations.

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• Event Insurance
  • Do event liability policies automatically provide workers' comp insurance?
    Do event liability policies automatically provide workers' comp insurance?

    No! That's a separate policy that has its own application.

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  • Do we need liquor liability?
    Do we need liquor liability?

    Probably not, which is good because it's really expensive! The only time you need liquor liability coverage is if you are selling the alcohol and retaining the money that you make. If that's the case, you also need a liquor license (and we'll need a copy of it) and someone with your event needs to complete a specific online intervention training program (which we also need proof of). Event insurance already includes some liquor coverage that is everything you need if you're giving the alcohol away.

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  • Does this policy include performer coverage?
    Does this policy include performer coverage?

    No; if you're doing an Equity showcase or have volunteer performers you'll need to get a volunteer accident policy, which is different coverage. If you have performers you are paying then you may want to look into a workers compensation policy.

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  • How much does it cost?
    How much does it cost?

    Every event is different, but the minimum is $380 and as always, it can go up from there.

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  • Is there a deductible?
    Is there a deductible?

    No, not on the liability insurance policies.

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  • What are the limits?
    What are the limits?

    Generally, $3 million aggregate (the total that the insurance company will pay out); $1 million each occurrence; $1 million personal and advertising injury; $3 million products and completed operations. This can vary based on each policy, but these are the typical limits for the event insurance program.

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  • What can be insured under these policies?
    What can be insured under these policies?

    All sorts of things, as long as they're artistic! We've done plays, musicals, dance, opera, music, gallery openings, film screenings, poetry readings, gala fundraisers, music festivals, the list goes on!

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  • What if my event is in lots of venues or is really long?
    What if my event is in lots of venues or is really long?

    That's fine! But if you have lots of things going on throughout the year, you'll probably be better off with an annual policy.

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  • What is event liability insurance?
    What is event liability insurance?

    It's short-term liability insurance that covers you against claims related to damage to the venue and injury to spectators or innocent bystanders

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  • What isn't insured under these policies?
    What isn't insured under these policies?

    Events held in a private home, or anything that is not artistic. We can't do weddings.

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• Film Production and Equipment Insurance
  • How much does it cost?
    How much does it cost?

    They're always different, but the minimum cost of the film general liability is $500 and the equipment is also $500. As always, it can just go up from there.

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  • Is there a deductible?
    Is there a deductible?

    On the general liability, no! On the equipment, yes! It's usually $1000, but it's higher for some losses like by earthquake or hail.

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  • What are the limits?
    What are the limits?

    $2 million general aggregate (the total that the insurance company will pay out); $1 million per occurrence; $1 million personal and advertising injury. The equipment insurance covers however much equipment value you request on the original application.

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  • What can be insured under these policies?
    What can be insured under these policies?

    Film or video production! Just so you know, music videos are difficult and we can't do pornography.

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  • What's film production insurance? What's equipment insurance?
    What's film production insurance? What's equipment insurance?

    Film production is an annual general liability policy that will cover you for your filmmaking activities (regardless of location, as long as you are in the US) for an entire year. Equipment insurance is a policy that will cover loss, damage, theft, etc. to your rented or owned equipment.

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• Fire Performer Insurance
  • Can you insure Canadian groups?
    Can you insure Canadian groups?

    Not unless you have a US tax ID. Our program is only available to entities with a US tax ID (social security number or employer identification number).

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  • Do fire performance liability policies automatically provide workers' comp insurance?
    Do fire performance liability policies automatically provide workers' comp insurance?

    Nope. That's a separate policy that has its own application.

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  • Does this policy include performer coverage?
    Does this policy include performer coverage?

    No; if you have volunteer performers you'll need to get a volunteer accident policy, which is different coverage. If you have performers you are paying then you may want to look into a workers compensation policy.

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  • How much does it cost?
    How much does it cost?

    They're always different, but most of our fire insurance quotes are in the $700-$1,300 range. Our staff can't guess what your quote will be, so we suggest signing up for membership and submitting a quote request. Once we get it back to you, which usually takes 3-5 business days, if you choose not to purchase the coverage through us, we would be more than happy to refund your membership dues.

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  • Is there a deductible?
    Is there a deductible?

    On the general liability, no.

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  • What are the limits?
    What are the limits?

    $2 million general aggregate (the total that the insurance company will pay out); $1 million per occurrence; $1 million personal and advertising injury.

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  • What can be insured under these policies?
    What can be insured under these policies?

    Fire performance!

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• General Information
  • About the Programs
    • Are all policies annual?
      Are all policies annual?

      Yes! The only ones that are not are event insurance, which is a short term liability policy, and travel accident insurance, which is tied to the specific trip for which you apply.

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    • Do I have to be a member to get insurance with you?
      Do I have to be a member to get insurance with you?

      Yes! Our insurance programs have been designed specifically for FA members. If you sign up and then decide not to get your insurance through us, we're happy to refund your membership dues. But we do have lots of other fabulous programs that may be useful, so check out the rest of the website!

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    • Does what I need insurance for have to be artistic in nature or arts-related?
      Does what I need insurance for have to be artistic in nature or arts-related?

      Yes! It does need to be artistic in nature. We are, after all, an arts service organization.

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    • How come Fractured Atlas staff cannot immediately answer all my questions?
      How come Fractured Atlas staff cannot immediately answer all my questions?

      Fractured Atlas is an arts service organization, not an insurance company. Our Liability Insurance programs are a service to our members and we work with insurance brokers and carriers to create these programs. Sometimes we must contact our broker's office or the insurance company itself to ensure that members receive a complete, correct answer.

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    • How come the rates are so low? It seems too good to be true!
      How come the rates are so low? It seems too good to be true!

      It's because we love you and fight hard to get you the best policies at the lowest rates possible. These programs are just for our members: you won't find them anywhere else.

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    • How long does it take to get coverage?
      How long does it take to get coverage?

      We'd love it if you give us at least ten business days, but we can usually do it in 3-5 if necessary. Some thing take lots of time, like workers comp and errors and omissions. Some things don't, like equipment coverage and volunteer accident insurance. If time is tight, stop reading this and fill out an application ASAP then give the office a call!

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    • Is Fractured Atlas an insurance company?
      Is Fractured Atlas an insurance company?

      Nope! We do have a licensed insurance broker on staff, but we work with insurance companies to get awesome policies at great rates for our members.

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    • What if I still have questions?
      What if I still have questions?

      Email us! That's always the fastest way to get an answer: shoot an email to support@fracturedatlas.org and we'll get back to you just as soon as possible, and definitely within one business day.

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    • What insurance companies do you work with?
      What insurance companies do you work with?

      We work with a number of different insurance companies to help make sure that we are providing the best policies at the lowest possible price. The ones that we do the most work with are The Hartford, Philadelphia, Chubb, Aspen, and Great American. We only work with A, A+, or A++ rated companies.

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  • Filling Out the Application
    • I can't get to the application!
      I can't get to the application!

      If you are already a member you need to make sure that you are logged on to the website. Not already a member? In that case you'll need to sign up. Once you've joined (as a full member, community members can't apply for insurance), you'll be able to log on and access the applications. Once you get the quote back, if you decide not to go with us then we are more than happy to refund your membership dues.

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    • I don't know how to answer some of these questions!
      I don't know how to answer some of these questions!

      We need a lot of information to get you a quote, and it's really important that it be correct. Some questions have little question marks next to them that help explain what we're looking for. There are also little white boxes with more information, or you can always look at these FAQs for the specific application you're trying to complete. Still confused? Email us at support@fracturedatlas.org or give the office a call. We deal with this every day and can totally help you figure it out.

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    • What is an "additional insured?"
      What is an "additional insured?"

      That's somebody that's not you who needs to be included in the policy. It's actually a really complicated question, but that's the simple answer. Sometimes venues or organizations ask to be included as additional insured and that's not a problem at all. Our policies generally come with unlimited additional insureds, and you can request certificates right through the "My liability insurance" portion of the website.

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  • Obtaining a Quote
    • Can I get a quote lower than the miniumum?
      Can I get a quote lower than the miniumum?

      No! The minimum quotes are the minimum quotes that we can give you. It doesn't get any lower. But you're always free to shop around and see what else you can find!

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    • Can I just get a ballpark figure without becoming a member and applying for a quote?
      Can I just get a ballpark figure without becoming a member and applying for a quote?

      Yes and no. Fractured Atlas staff members are not insurance underwriters and, therefore, we do not recommend asking us for a ballpark figure. We can try our best to offer a broad price range based on the quotes we've seen in the past, but the actual quote could be a lot lower or higher than what we present.

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    • Do I have to be a member to get a quote?
      Do I have to be a member to get a quote?

      Yes! We've worked hard to create these programs specifically for our members, so you do need to join first. If you decide not to get your insurance with us, we're of course more than happy to refund your membership dues. But we really do have some other fabulous programs, so spend some time on the website and see what we're all about!

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    • How do I apply for a quote?
      How do I apply for a quote?

      1. Become a member 2. Log on to the website 3. Go to "Insurance" under the "Programs and services" menu 4. Pick the program you need 5. Click "Apply today"

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    • How far in advance can I apply for a quote?
      How far in advance can I apply for a quote?

      We can't get you a quote if your event or start date is more than two months away. If you submit an application really far in advance, we could get you an indication (an idea of how much the premium will be) in case you need it for budgeting reasons.

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    • I don't like/I no longer need the quote. What should I do?
      I don't like/I no longer need the quote. What should I do?

      Let us know! If you think there's a problem or you just plain don't want it, we like to know so that we can either fix it or close out the application. It's as easy as hitting "Ask a question" on the "My liability insurance" page, and we'd really appreciate it!

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    • Is it free to apply for a quote?
      Is it free to apply for a quote?

      Yes. All members of Fractured Atlas can apply for liability insurance quotes for free.

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    • My quote is really high! What's up?
      My quote is really high! What's up?

      It happens! Some states are just plain expensive, and insurance underwriters are scared of a lot of things. We always do everything we can to get you the most affordable policy possible. If you get a quote that seems really high, email us! There's probably something we can do, or at the very least we can tell you what made it cost that much.

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    • Things have changed since I applied. What should I do?
      Things have changed since I applied. What should I do?

      We'll fix it! Let us know by revising your existing application. You'll find the "Edit" button next to each policy you applied for in the "My liability insurance" section of the website.

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    • What do I do once I receive the quote?
      What do I do once I receive the quote?

      Read it! They're a little dense, but it's really not as scary as it seems and there's a lot of important information there. Once you've had a peek at it, if there's anything at all you're wondering about go ahead and hit the "Ask a question" button on the My Liability Insurance page. We'll get right back to you with answers. If everything looks good, you can buy the policy right there on the website.

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    • What happens if you can't get me a quote?
      What happens if you can't get me a quote?

      We'll let you know as soon as we find out! There are some things that are hard to cover: music videos, aerial work, rap concerts . . . We'll always keep looking even if you originally get turned down. And we'll keep you posted on our progress! Unfortunately, there have been things that we've had to say no to, but we always try to give you ideas of where else to look.

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  • Purchasing the Insurance
    • How do I get a copy of my policy?
      How do I get a copy of my policy?

      Usually the insurance company will send you a paper copy 3-4 weeks after you purchase the coverage. For other policies, we'll upload a PDF of the policy on to the Fractured Atlas website. You can download it from the "My liability insurance" portion of the website within a few weeks of purchasing the quote.

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    • I need insurance certificates!
      I need insurance certificates!

      That's great! You need to request them online. Once you've purchased the policy, there will be a big green button on your "My liability insurance" page that says "Request certificates". Hit that, fill out the information, and you'll get an email with your certificates attached within one business day. Need them faster? Email support@fracturedatlas.org and let us know.

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    • The quote looks great! How do I purchase the insurance?
      The quote looks great! How do I purchase the insurance?

      Follow the instructions online! Go to "My liability insurance" and the site will walk you through the rest.

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    • What's the binder fee?
      What's the binder fee?

      It's an administrative fee to Fractured Atlas that makes this program possible!

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• Public Art Insurance
  • How much does it cost?
    How much does it cost?

    They start at $425 for the liability insurance and can go up from there.

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  • Is there a deductible?
    Is there a deductible?

    For the liability policy, no! For the artwork, yes! It's $1000 unless the damage is due to earthquake, hail, or wind, and then it's $10,000

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  • What are the limits?
    What are the limits?

    $2 million general aggregate (the total that the insurance company will pay out); $1 million each occurrence; $1million personal and advertising injury; $300,000 fire damage legal liability; $10,000 medical expense coverage per occurrence; and $1,000,000 for rented vehicles

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  • What can be insured under these policies?
    What can be insured under these policies?

    This insurance covers static works of visual art (sculptures, mainly) that are in areas accessible by the public.

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  • What is public art liability insurance?
    What is public art liability insurance?

    It's liability coverage that protects you against claims for damage to a location or injury to a spectator or innocent bystander during fabrication, installation, and exhibition. Do note that this does not automatically include coverage for damage to the artwork itself, so you're covered if the art hurts someone but not if someone hurts the art. That's a separate policy.

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  • What isn't insured?
    What isn't insured?

    Performing arts. That's a separate policy.

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• Volunteer Accident Insurance
  • Can you obtain volunteer accident insurance for any state?
    Can you obtain volunteer accident insurance for any state?

    Absolutely. This policy covers volunteers in all states.

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  • How much does it cost?
    How much does it cost?

    $175 for the year.

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  • Is there a deductible?
    Is there a deductible?

    Yes! Usually there's a $250 deductible.

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  • What are the limits?
    What are the limits?

    $500,000 of coverage per accident, with $50,000 in medical expenses (primary medical coverage) available immediately per volunteer per accident. For certain accidents, including those involving automobiles, the medical expense limit may differ.

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  • What can be insured?
    What can be insured?

    Any arts-related organization or artist with volunteer workers

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  • What is volunteer accident insurance?
    What is volunteer accident insurance?

    Volunteer accident insurance provides annual insurance to cover medical care for volunteer employees who are injured while on the job. This can be used to cover volunteer performers (including those in Equity Showcase performances and in films with unpaid SAG actors) or for any volunteer that is working under your auspices as an artist or arts organization. A volunteer is defined as someone who is an unpaid worker (or someone who is being paid via a stipend reimbursing them for their direct expenses) and who is not on payroll/salary.

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  • What isn't insured?
    What isn't insured?

    Paid workers: you'll need a workers compensation policy for that.

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• Workers Compensation Insurance
  • Can you obtain worker's comp quotes for any state?
    Can you obtain worker's comp quotes for any state?

    No. We can't get quotes for North Dakota, Ohio, Washington, West Virginia, and Wyoming. Because of state laws, workers comp in those states has to be purchased through a state agency.

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  • How much does it cost?
    How much does it cost?

    It's always different! It depends on what state, how many employees, how much payroll, even what exactly you are doing. We can tell you that the minimum quote we've received so far, for an organization with very little payroll and just a few employees, is about $400.

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  • Is there a deductible?
    Is there a deductible?

    Nope!

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  • What are the limits of this insurance?
    What are the limits of this insurance?

    Generally, it's $100,000 per accident and a $500,000 aggregate, but you should always check the quote to see if it's listed.

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  • What can be insured under these policies?
    What can be insured under these policies?

    Any arts-related organization can apply to this program.

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  • What is worker's comp insurance?
    What is worker's comp insurance?

    It's coverage for paid employees in case they are injured on the job. Worker's comp pays medical bills before an individual's health insurance kicks in. Have volunteers? Check out our volunteer accident policy instead.

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  • What isn't insured under these policies?
    What isn't insured under these policies?

    Disability insurance is not included in these policies unless the organization is based in New York, at which point our broker will obtain such a policy, as it's required.

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• Health Insurance
  • Health Insurance Concepts
    • What is a copay?
      What is a copay?

      A copay is a cost sharing system between you and the insurance company. You pay a flat fee, such as $25 for a doctor's office visit, required at the time any covered medical service is received. The insurance company is responsible for the difference. There may be different copays depending upon type of provider or service.

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      Don't sue us! Fractured Atlas is not an insurance company. We're also not lawyers, brokers, agents, doctors, or anyone else qualified to give professional advice. We try our best to be helpful, but take anything written here with a handful of salt.
    • What is a deductible?
      What is a deductible?

      A deductible is the fixed dollar amount you must pay of your own funds each calendar year before your health insurance begins to make payments for covered medical services.

      All deductibles reset once a year on January 1. Typically, the higher the deductible, the lower the premiums and vice versa. Deductible amounts usually differ out of network (proving to be higher).

      When selecting a plan, you should know what plan benefits are subject to the deductible, and what portion of the cost (set as percentages) is covered by the plan once it has been met. This is typically referred to as coinsurance. If the cost is covered 100% after the deductible, then coinsurance is not applicable. See "What is co-insurance?"

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      Don't sue us! Fractured Atlas is not an insurance company. We're also not lawyers, brokers, agents, doctors, or anyone else qualified to give professional advice. We try our best to be helpful, but take anything written here with a handful of salt.
    • What is a formulary prescription?
      What is a formulary prescription?

      A formulary list is a pre-approved list of preferred generic or brand name prescriptions that is covered under a healthcare plan. The list is determined by the insurance company and may be subject to change at any time.

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      Don't sue us! Fractured Atlas is not an insurance company. We're also not lawyers, brokers, agents, doctors, or anyone else qualified to give professional advice. We try our best to be helpful, but take anything written here with a handful of salt.
    • What is a full featured plan?
      What is a full featured plan?

      Full featured plans are also commonly called "traditional" healthcare plans that typically offer comprehensive coverage for a wide range of medical care, services, and treatment. As a result, these plans generally are more expensive as they provide for greater protection from larger medical expenses.

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      Don't sue us! Fractured Atlas is not an insurance company. We're also not lawyers, brokers, agents, doctors, or anyone else qualified to give professional advice. We try our best to be helpful, but take anything written here with a handful of salt.
    • What is a limited benefit plan?
      What is a limited benefit plan?

      Quite often called a "bare bones" plan, limited benefit plans provide much lesser benefits than a traditional health insurance plan in exchange for much lower premiums. When considering these plans, it is important to know exactly what types of care or services the plan will or will not pay for and how much coverage it actually provides. These plans usually include pre-existing conditions exclusions.

      While the plan administrators of most of these plans are HIPAA compliant (meaning they must follow certain aspects of HIPAA, ie. privacy rights and other regulations), these plans are not considered to be continuous creditable coverage under HIPAA as there are certain qualifications a health plan must meet in order to be considered continuous credible coverage.

      As a result, you may be subject to an exclusionary wait period for any pre-existing conditions that existed before your enrollment start date in a full featured healthcare plan, (such as a group or individual plan)if your prior coverage was under a limited benefit plan. The maximum look back period for pre-existing conditions before your enrollment start date may differ upon the insurance carrier and state/federal law.

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      Don't sue us! Fractured Atlas is not an insurance company. We're also not lawyers, brokers, agents, doctors, or anyone else qualified to give professional advice. We try our best to be helpful, but take anything written here with a handful of salt.
    • What is a medical discount plan?
      What is a medical discount plan?

      A medical discount plan is not insurance and doesn't pay for any of your costs, but offers reduced rates on eligible services by participating network providers. Reduced rates vary by provider and type of services received. It is your sole responsibility to pay all health bills incurred out of pocket.

      While NOT insurance, this provides an affordable alternative for individuals looking to minimize their out of pocket healthcare costs.

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      Don't sue us! Fractured Atlas is not an insurance company. We're also not lawyers, brokers, agents, doctors, or anyone else qualified to give professional advice. We try our best to be helpful, but take anything written here with a handful of salt.
    • What is a PPO?
      What is a PPO?

      PPO stands for Preferred Provider Organization. This is a type of health insurance plan that offers in-network as well as out-of-network coverage. However, out-of-network coverage is typically subject to either a higher deductible or lower co-insurance than in-network, often times both. No referrals are required in order to access care.

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      Don't sue us! Fractured Atlas is not an insurance company. We're also not lawyers, brokers, agents, doctors, or anyone else qualified to give professional advice. We try our best to be helpful, but take anything written here with a handful of salt.
    • What is an annual maximum?
      What is an annual maximum?

      An annual maximum the maximum dollar amount an insurance company will pay over the benefit of a year for all covered expenses.

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      Don't sue us! Fractured Atlas is not an insurance company. We're also not lawyers, brokers, agents, doctors, or anyone else qualified to give professional advice. We try our best to be helpful, but take anything written here with a handful of salt.
    • What is an EPO?
      What is an EPO?

      EPO stands for Exclusive Provider Organization. This is a type of health insurance plan that offers in-network coverage only. Enrollees must select in-network providers when seeking medical care, services, or treatment. No referrals are required in order to access care.

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      Don't sue us! Fractured Atlas is not an insurance company. We're also not lawyers, brokers, agents, doctors, or anyone else qualified to give professional advice. We try our best to be helpful, but take anything written here with a handful of salt.
    • What is an HMO?
      What is an HMO?

      HMO stands for Health Maintenance Organization. This is a health insurance plan that offers comprehensive health services with only modest co-pays and no deductibles or co-insurance. This plan features in-network coverage only. Referrals are required for any specialized medical care or service and are issued by your primary care physician (PCP) as need be.

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      Don't sue us! Fractured Atlas is not an insurance company. We're also not lawyers, brokers, agents, doctors, or anyone else qualified to give professional advice. We try our best to be helpful, but take anything written here with a handful of salt.
    • What is an HSA (Health Savings Account)?
      What is an HSA (Health Savings Account)?

      An HSA is a special type of account that offers tax benefits on money put aside for future medical expenses. Anyone who buys a qualified high deductible health plan (one that meets the requirements the government has determined), qualifies for an HSA.

      You enjoy tax-deductible contributions, tax-deferred interest and tax-advantaged withdrawals for qualified medical expenses (these do NOT count towards meeting your deductible) OR for eligible expenses that qualify towards meeting your deductible. See "What is an eligible expense?" and "What is a qualified medical expense?" Unused balances from year to year roll over from year to year.

      Please refer to the IRS website for all applicable HSA guidelines which must be adhered to: IRS.

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    • What is co-insurance?
      What is co-insurance?

      Co-insurance is a policy provision under which you and the insurance company share the total cost of covered medical services after the deductible has been met set as fixed percentages.

      For illustrative purposes, a particular plan may provide 75/25% coinsurance (after a $2,000 deductible has been met) up to a specified amount called the coinsurance out of pocket maximum (in this case $3,000).

      This means that you'll pay the the first $2,000 of covered expenses subject to the deductible. Then, you'll pay 25% of all covered expenses up to the point that you've paid $3,000, (while the insurance company pays 75%). After that, the plan typically pays 100% of covered charges for the remainder of the year on an in network basis, up to the policy maximum.

      Please note that coinsurance percentages and coinsurance out of pocket maximums differ out of network with you covering a greater portion of the cost overall. Once met, most policies typically only cover the maximum allowable amount of the usual and customary rate (UCR). You can be balanced billed for the difference. See "What is the usual and customary rate (UCR)?"

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    • What is the total out-of-pocket maximum?
      What is the total out-of-pocket maximum?

      The maximum dollar amount that must be met by you out of your own funds during the benefit period, before the insurance company pays 100% of all covered expenses, usually up to an annual or lifetime maximum.

      Before this maximum is met, you and the insurance company share the cost of all covered expenses as set by the co-insurance after the initial deductible has been met. The amount is determined by adding your deductible and coinsurance out of pocket maximum together.

      For instance, if you have a $3,000 deductible and a coinsurance out of pocket maximum of $5,000, then your total annual expenses is $8,000 for eligible medical benefits. Regular premiums do not count towards meeting the maximum out-of-pocket total.

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    • What should I look for when evaluating health insurance choices and choosing the right plan for me?
      What should I look for when evaluating health insurance choices and choosing the right plan for me?

      Although everyone's individual needs are different, there are key factors that you should look at when making a fully informed choice for one plan over another. Here are several key questions you should ask yourself when looking over your healthcare options.

      When looking over your healthcare options, ask yourself:

      • How all-inclusive do I want coverage of healthcare services to be?
      • How much am I willing to spend on premiums?
      • What type of healthcare plan is this, ie. a medical discount plan, limited benefit plan, or a full featured plan?
      • Is it a group plan or an individual health insurance policy?
      • Is this plan considered to be continuous credible coverage under HIPAA?

      You should also make separate checklists and see what type of benefit coverage each plan offers for the following:

      • Preventative Care
      • Care by Specialists
      • Hospitalization
      • Emergency Care
      • Prescriptions
      • Mental Healthcare

      For each one, find out how much is your responsibility to pay or what circumstances, if at all, apply, before the plan begins to cover for each type of care or treatment. For instance:

      • What co-payments must you pay for certain types of services?
      • Are there any deductibles that must be met by you before the insurance starts to cover the cost?
      • If the deductible is met, what portion of the cost is paid by the plan?
      • How much will you have to pay if you go out-of-network?
      • Are there any limits to how much the insurance company pays over a given benefit period, for instance over a year or a lifetime?

      After you’ve done that, you are now ready to ask yourself: Is there a complimentary fit between what is provided under any particular plan and what you think you’ll need?

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  • HIPAA Rules
    • How would health insurance providers know if I have a pre-existing condition?
      How would health insurance providers know if I have a pre-existing condition?

      Once coverage begins under any given health plan, any claims filed by you may be investigated as a possible pre-existing condition. Depending on state law, insurers can look back months or even years to see if the condition existed before your enrollment.

      If evidence is found, insurers can deny any claims or benefit coverage for that condition and all care/treatment related to it. However, only in the case of HIPAA qualified creditable coverage group health plans, the maximum look back period is six months.

      *States also differ upon which standard is used in defining a "pre-existing condition." Some states use the "objective standard," which defines a "pre-existing condition" as anything for which you've received medical advice, diagnosis, care, or treatment.

      Conversely, most states support a much broader definition based on the "prudent person" standard. Under this standard, a "pre-existing condition" also includes anything may not been diagnosed, but showed symptoms for which an "ordinarily prudent person" would have sought medical advice, diagnosis, care, and treatment.

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    • I've had a medical condition in the past. Can my plan deny coverage under the claim that it's a pre-existing condition?
      I've had a medical condition in the past. Can my plan deny coverage under the claim that it's a pre-existing condition?

      Under HIPAA qualified continuous creditable coverage group health plans, it would in all actuality be dependant upon whether or not you had received any type of medical advice, care, or treatments within a six month period prior to the effective start date of your enrollment.

      If it has been longer than six months since you've received any medical advice or care related to that condition, then it cannot be subject to a pre-existing condition exclusionary wait period. *This is not applicable to individual health insurance policies.

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    • If I get coverage as a sole proprietor or self-employed individual, how does this differ from a group health plan or an individual plan?
      If I get coverage as a sole proprietor or self-employed individual, how does this differ from a group health plan or an individual plan?

      Technically, this depends upon state law and the insurance carrier. For instance, in NY, individuals are eligible for "group coverage" as a sole proprietor. Essentially, under NY state law, sole proprietors are enrolling in group coverage as a "group of one." These differ from individual health policies which are not considered to be group coverage, and as such, are subject to state laws while group coverage are subject to state and federal laws, including HIPAA.

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    • What does not qualify as creditable continuous coverage under HIPAA?
      What does not qualify as creditable continuous coverage under HIPAA?

      In most cases, limited benefit plans and medical discount programs are not considered to be creditable continuous coverage and should not be mistaken for major medical or full featured plans.

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    • What is a pre-existing condition and what's the difference between the "objective standard" and the "prudent standard" of the definition of a pre-existing condition?
      What is a pre-existing condition and what's the difference between the "objective standard" and the "prudent standard" of the definition of a pre-existing condition?

      A pre-existing condition is a medical condition or healthcare problem that existed before enrolling in a healthcare plan. The "objective standard" of the definition states that a pre-existing condition is anything for which you've received medical advice, care, diagnosis and treatment prior to your enrollment.

      By contrast, the "prudent standard" of the definition states that a pre-existing condition is any condition for which symptoms were present although medical advice, care, diagnosis, or treatment may not have been received prior to enrollment. Under the "prudent standard," an "ordinarily prudent" individual surely would have sought medical advice, care, diagnosis, or treatment for any symptoms that were present prior to enrollment.

      Most states implement the prudent standard of the definition.

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    • What is a pre-existing condition, as defined under HIPAA?
      What is a pre-existing condition, as defined under HIPAA?

      A pre-existing condition is anything for which medical advice, diagnosis, care, or treatment was recommended or received within six months before the effective start date of enrollment in a group healthcare plan. Under the law, group health plans may not impose an exclusionary wait period for pre-existing conditions longer than 12 months (or 18 months for late enrollees). *This is not applicable to individual health insurance policies.

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    • What is a state high risk pool?
      What is a state high risk pool?

      State high risk pools are state programs that offer health insurance to "uninsurable" individuals who are unable to obtain health insurance coverage through a group plan, are ineligible for Medicaid/Medicare, and cannot afford an individual health insurance policy.

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    • What is and qualifies as creditable coverage under HIPAA?
      What is and qualifies as creditable coverage under HIPAA?

      Creditable coverage is defined as certain types of prior health insurance coverage that may qualify in order to shorten or waive a pre-existing condition waiting period. This includes most comparable group healthcare plans, in certain cases, individual health insurance policies, Medicaid, Medicare, COBRA, state health benefits risk pools, the Peace Corps Act, or public healthcare plans.

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    • What is HIPAA?
      What is HIPAA?

      HIPAA stands for the Health Insurance Portability and Accountability Act. This is a federal law that offers you certain protections when transferring your healthcare coverage from one plan to another, limits exclusions for pre-existing conditions, includes provisions that address privacy and security of health data, and prohibits discrimination against you based on your health status, disability, medical history, or genetic information.

      *All aspects of HIPAA regulation may not be applicable to individual health insurance policies.

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    • What is the difference between individual health insurance plans and group health plans?
      What is the difference between individual health insurance plans and group health plans?

      A group health plan covers a group of people and is subject to state and federal law. Group plans are traditionally offered by employers, unions, and trade and member associations. Individual health insurance plans are subject to state laws which differ from state-to-state. When considering individual health insurance plans, ask yourself the following questions:

      • What are the rules and regulations for individual health policies in my state?
      • Am I a "HIPAA eligible" individual and if so, is this individual policy applicable to HIPAA rules and regulations?

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    • What types of healthcare plans are not subject to HIPAA and why?
      What types of healthcare plans are not subject to HIPAA and why?

      HIPAA is a federal law that applies to group health plans and is enforced by the Secretary of Labor. Private health insurance, on the other hand, is state regulated. Therefore, the individual health insurance market must adhere to all state rules and regulations of any given particular state. All state rules and regulations differ from state to state and exclusions may apply as appropriate.

      Individual health insurance policies or state high risk pool plans are not subject to HIPAA except in the case where it grants access to individual healthcare policies for "HIPAA eligible" individuals only.

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    • When would I be subject to an exclusionary wait period for pre-existing conditions under HIPAA continous creditable coverage, such as a group health plans?
      When would I be subject to an exclusionary wait period for pre-existing conditions under HIPAA continous creditable coverage, such as a group health plans?

      You may be subject to an exclusionary waiting period for pre-existing conditions if any of the following conditions apply:

      • You are not currently insured but sought medical advice, care, or treatment within the last six months before the effective start date in any given health insurance plan
      • If you were previously insured, but there's been a gap in coverage longer than 63 days
      • You currently are insured, but your current health insurance plan does not qualify as creditable coverage

      *Note: Group health plans may not impose a pre-existing condition exclusionary waiting period for pregnancy whether or not the woman had previous health coverage.

      In addition, a pre-existing exclusionary wait period may not be applied to newborns, newly adopted children or children placed for adoption under 18, as long as the child was covered within 30 days of the date of birth, adoption or placement for adoption and provided there was no significant break of coverage longer than 63 days.

      *This is not applicable to individual health insurance policies.

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    • Who qualifies as a "HIPAA eligible" individual?
      Who qualifies as a "HIPAA eligible" individual?

      "HIPAA eligible" individuals must have exhausted all options for coverage under any group plan and must meet all of the following criteria:

      • Have had continuous coverage for a minimum of 18 months with the most recent period under a group health plan without a significant break in coverage of more than 63 days in a row.
      • Have been offered the option for continuation of COBRA coverage, and have elected and exhausted it, or are ineligible for continuation of COBRA coverage altogether, or other similar state programs
      • Did not have their group coverage terminated because of nonpayment of premiums or fraud
      • Are not eligible for coverage under another group plan, Medicaid, or Medicare.

      In this case, only applicable individual health policies or state high risk pool plans may not exclude coverage for pre-existing conditions nor turn down an application for coverage only if all of the criteria is met as a "HIPAA eligible" individual and the individual applied within 63 days of the last date of coverage under a group plan.

      Individual market carriers may elect their two most popular individual health policies or "representative plans" for "HIPAA eligible" individuals. These are the only plans that may not impose pre-existing condition exclusions, but HIPAA does not limit premium rates on these individual policies.

      *Note: all "HIPAA eligible" individuals must apply to the appropriate entity as mandated by their state of residency. For instance, some states guarantee access to healthcare for "HIPAA eligible" individuals to high risk pools only, while other states guarantee access to all individual markets carriers, or both.

      Individual market carriers may impose a wait period for pre-existing conditions or deny coverage to "HIPAA eligible" individuals if access to non-group healthcare is provided by state high risk pools only.

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