Insurance Advantage Insurance & Mortgage Group Concord North Carolina

Types of Automobile Coverage

Liability
Your liability coverage will pay for bodily injury and property damage for which any covered individual becomes legally responsible. The Personal Automobile Policy will cover you or any family member while using any automobile or trailer, and any person using your covered automobile with permission. The policy will pay up to the limits listed in your policy.

Collision
Collision means physical damage to your covered vehicle caused by an impact with another vehicle or object. This coverage pays the lesser of the cost of repair or Actual Cash Value (ACV) of your automobile.

Other than Collision (Comprehensive)
This coverage pays the cost of repair or ACV of your automobile less any deductible. Losses caused by the following are considered comprehensive claims:
Missiles or falling objects;
Fire;
Theft or larceny;
Explosive or earthquake;
Windstorm;
Hail, water or flood;
Malicious mischief or vandalism;
Riot or civil commotion;
Contact with a bird or animal; or
Breakage of glass.

Medical Payments Coverage
This coverage pays for reasonable and necessary medical and funeral expenses due to an automobile accident. Individuals covered under this coverage include:
You or any family member while occupying any automobile, or as a pedestrian when struck by a motor vehicle; or
Any other person while occupying your covered automobile or any vehicle (private passenger automobile or trailer licensed for road use) driven by you or a family member.
The policy will pay up to the limits listed in your policy for each individual injured.

The medical payments coverage will not provide coverage for any expenses if the injuries occur while occupying a motorized vehicle with less than four wheels.

Uninsured Motorists (UM) Coverage
Your Uninsured Motorist Coverage will provide protection when an uninsured driver, who is at-fault, injures you or another covered individual. It also provides property damage coverage.

Underinsured Motorists (UIM) Coverage
This coverage will provide protection when an underinsured driver, who is at-fault, causes injury to a covered individual. An underinsured driver is one whose limits of liability are less than your UIM limits, and not enough to cover the losses of the people the underinsured driver injures in an at-fault accident.

UIM coverage does not provide protection against property damage. The UIM coverage will pay a maximum of the difference between the other driver's Liability limits and your UIM limits.

Caution: Your insurance company will not provide coverage if you or your legal representative settles the bodily injury or property damage without the company's written consent.
This information provided by the North Carolina Department of Insurance.

Types of Insurance for Your Business

Liability
BOP policy (Business Owner's Policy)
A package of insurance coverages for the small business owner. It includes liability, products and completed operations, and can add coverages for a building, business property and equipment. Can also include Commercial Auto and Workman's Comp. depending on the type of business.

Commercial General Liability
A basic business liability policy to cover damages done by you or your employees to a clients property or medical claims. Rate is based on experience, number of employees, and gross annual receipts.

Commercial Automobile
Virtually every business today needs a vehicle of some type: private passenger type, van, bus, or tractor trailer. A business needs to insure against damage to their own vehicles, injuries to 3rd parties, damage to cargo, and injuries to persons riding in their vehicles. The minimum limits are 30/60/25 and for certain commercial autos the limits are much higher. It would not be unreasonable to shop around for the best price or service Rating of commercial auto policies are different from your personal auto. There is no standardization of policies, rates, or rating procedures. When seeking insurance, most insurers want to know the attitude of all parties toward traffic laws and safety. Other factors include condition of vehicles, driver experience, driver training, driver supervision, hazards of the route, loading and unloading, motor vehicle records, use of non-owned vehicles, and vehicle security.

Group Health Insurance
Individual and Small Employers (1-50 employees)

Group Health Insurance Plan Provisions
The following requirements apply to employer-based health benefit plans that provide major medical benefits. The requirements do not apply to medical payments under auto, workers compensation, or disability insurance nor to policies providing limited coverage of medical services such as Medicare supplement insurance and dental and vision plans.

Nondiscrimination/"Whole Group" Coverage
An insurer may not establish "rules of eligibility", including rules related to late enrollment, of any individual to enroll in an employer-based health plan which are based upon any health status-related factor. Such factors include (with respect to an individual or dependent) health status, medical condition (including both physical and mental illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of insurability and disability. This includes prohibiting an insurer from singling an individual out from the group to pay different premium or contribution based upon some health status-related factor.

Limitations on Pre-existing Condition Exclusions
A pre-existing condition is generally defined as an injury that occurred or sickness that was present before the policy was issued and that was not disclosed on the application. If you receive treatment or medical advice for an injury or sickness before the policy is issued, you should list all treatments and medications on your application, if health questions are asked.

An insurer may apply a preexisting condition exclusion with respect to an individual who is covered by an employer-based group health plan only if:
The exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period ending on the enrollment date.
The exclusion extends for a period of not more than 12 months, or 18 months in the case of a late enrollee.
The period of any preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage, if any, applicable to an individual who is covered by an employer-based group health plan as of the enrollment date.
Creditable coverage means that you were covered under another major medical or similar qualified health benefit plan. If you were continuously covered by this plan, and have no more than a 63-day break in coverage, you qualify for the preexisting credit.

An insurer may not apply a pre-existing condition exclusion in the following cases:
In the case of an individual who, as of the last day of the 30-day period beginning with the individual's date of birth, is covered under creditable coverage.
In the case of a child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last date of the 30-day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage.
No group health insurer shall impose a pre-existing condition limitation relating to pregnancy as a pre-existing condition.

A period of creditable coverage shall not be counted if, after the period and before the enrollment date under an employer-based health plan, there was a 63-day period during all of which the individual was not covered under any creditable coverage.

Any period that an individual is in a waiting period for any coverage under an employer-based health plan or is in an affiliation period shall not be taken into account in determining the continuous period of creditable coverage.

An insurer may accept prior coverage without regard to the benefits covered (one day of creditable coverage = a reduction by one day of the pre-existing condition exclusion), or may elect to evaluate prior coverage on a class or category-of-benefits basis.

Periods of creditable coverage shall be established through the presentation of a certification of creditable coverage or in another manner permitted under federal law. An insurer shall provide a certification of creditable coverage to an individual at the following times:
At the time an individual ceases to be covered under the plan or otherwise becomes covered under a continuation provision (COBRA or State continuation).
In the case of an individual becoming covered under a continuation provision, at the time the individual ceases to be covered under the continuation provision.
On the request or behalf of the individual made not later than 24 months after the date of cessation of the coverage under the plan or under a continuation provision whichever is later.

The enrollment date with respect to an individual who is covered by an employer-based group health plan is defined as the date of enrollment of the individual in the coverage or if earlier, the first day of the waiting period for the enrollment.

The waiting period with respect to an individual who is a potential participant in an employer-based group health plan is defined as the period that must pass with respect to the individual before the individual is eligible to be covered for the benefits under the terms of the plan.

Creditable coverage, is defined with respect to an individual, coverage of the individual under any of the following, except creditable coverage does not include coverage consisting solely of coverage of "excepted benefits" – those benefits provided under the following types of plans:
A self-funded employer group health plan under the Employee Retirement Income Security Act of 1974 (ERISA).
Group or individual health insurance coverage.
Part A or Part B of Medicare.
Medicaid.
CHAMPUS (medical and dental care for members and certain former members of the uniformed services and for their dependents).
A medical care program of the Indian Health Service or of a tribal organization.
A State health benefits risk pool.
The Federal Employees Health Benefit Program.
A public health plan (any plan established or maintained by a State, county, or other political subdivision of a State that provides health insurance coverage to individuals who are enrolled in the plan).
A health benefit plan under section 5(e) of the Peace Corps Act.
The Health Insurance Program for Children established in Part 8 of Chapter 108A of the North Carolina General Statutes or any successor program.

A certification of creditable coverage is a written certification of the period of creditable coverage for the individual under the plan and any coverage under the continuation provision (COBRA or State continuation) and any waiting periods imposed with respect to the individual for any coverage under the plan.

Guaranteed Availability of Small Group Products
Insurers who serve the small employer market (employers with 50 or less full-time employees) are required to accept every small employer that applies for coverage under any health plan the insurer actively markets in the small group market and to accept every individual and their dependents in the group who applies when they first become eligible for coverage under that plan. An insurer may refuse to issue coverage only if the insurer has a financial incapacity, an inadequate network, the applicant is not in the insurer's service area, or if the group fails to meet the minimum participation and/or contribution requirements of the insurer.

Guaranteed availability of all small group coverage is not extended to self-employed individuals under North Carolina insurance law even though such persons are considered small employers. However, such people are guaranteed access to two standardized health plans from any insurer who is serving the small employer market. (Put in link to self-employed individual section).

Guaranteed availability of coverage is not extended to large employer groups (groups with more than 50 full time employees).

Guaranteed Renewability of Group Coverages
Insurers are required to guarantee the renewability of the group health plan to the employer except for the following reasons:
The policyholder fails to pay premiums.
The policyholder committed fraud or made a material misrepresentation.
The policyholder fails to comply with the participation and/or contribution requirements of the insurer.
The insurer is terminating the plan type or is terminating all coverage in the market place because of a decision to cease offering coverage in the State. If an insurer ceases offering a type of plan, the insurer must give the insureds a 90-day notice of the termination and offer the policyholder replacement coverage from all plans the insurer currently markets in that market. If an insurer is leaving the market in this State, the insurer must give the insureds a 180-day notice of the termination.
The policyholder moves outside the insurer's service area and no insured lives, works, or resides in the service area.
The employer's membership in a bona-fide association ceases.

A bona-fide association is an association that has been actively in existence for at least five years, has been formed and maintained for purposes other than of obtaining insurance, does not condition membership in the association on any health status-related factor relating to an individual, makes coverage offered through the association available to all members regardless of any health status-related factors, and does not make health insurance coverage offered through the association available other than in connection with a member of the association.

Large Employers (50+ employees)

Limitations on Pre-existing Condition Exclusions
A preexisting condition is generally defined as an injury that occurred or sickness that was present before the policy was issued and that was not disclosed on the application. If you receive treatment or medical advice for an injury or sickness before the policy is issued, you should list all treatments and medications on your application, if health questions are asked.

An insurer may apply a pre-existing condition exclusion with respect to an individual who is covered by an employer-based group health plan only if:
The exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period ending on the enrollment date.
The exclusion extends for a period of not more than 12 months, or 18 months in the case of a late enrollee.
The period of any pre-existing condition exclusion is reduced by the aggregate of the periods of creditable coverage, if any, applicable to an individual who is covered by an employer-based group health plan as of the enrollment date.
Creditable coverage means that you were covered under another major medical or similar qualified health benefit plan. If you were continuously covered by this plan, and have no more than a 63-day break in coverage, you qualify for the pre-existing credit.

Types of Health Insurance

Major Medical (Traditional Health Plans)
A policy designed to reimburse the insured for excess medical expenses in and out of the hospital. The policy usually includes a deductible, a coinsurance clause and an aggregate limit.

Managed Care Plans (HMOs and PPOs)

Health Maintenance Organizations (HMOs)
An entity with four essential characteristics:
A n organized system for providing health care in a geographic area,
delivering an agreed upon set of basic and supplemental health maintenance and treatment services mental health maintenance and treatment services
to a voluntarily enrolled group of persons
for which services the HMO is reimbursed through a predetermined and periodic prepayment made by or on behalf of each person or family unit enrolled in the HMO, without regard to the amounts of actual services provided.

What is Managed Care
The term "managed care" refers to a variety of techniques used by health plans to manage both the cost and the quality of health care services for their members: Delivering the right care at the right time, in the most cost-effective setting.

HMOs and PPOs are referred to as managed care plans because they use the broadest array of techniques to manage costs and medical services. While HMOs and PPOs differ, these are some of the most common techniques they both use to manage cost and quality:

HMOs and PPOs contract with doctors, hospitals and other health care providers, using specific criteria to determine which providers will participate in their network.
HMOs and PPOs design their benefits to encourage plan members to use the plan provider network.
HMOs and PPOs use a utilization review program to manage the care provided and control the plan's total medical expenditures.
Some HMOs and PPOs have a drug formulary that limits coverage to those drugs in the formulary.

How Do HMO and PPO Plans Differ?
If you have the option of choosing from two or more plans, you should consider some of the differences between them. Aside from the obvious differences in covered benefits, benefit levels (how much the plan pays), and premiums, the following are some points on how plans may differ from one another.

Utilization Review (UR) Programs
Both HMOs and PPOs manage their members' use of medical services to make sure that only necessary treatments are received and services are provided in a medically appropriate and cost-effective manner. UR programs use established medical review criteria to determine whether the plan will "certify" (authorize) a requested services, continue to provide coverage for on-going treatment or pay for a service that has already been received.

Plans differ in how they approach UR. Some plans' UR program requires providers to contact the plan for most approvals, other plans leave some of the individual UR decisions to the provider.
Plans also differ in the medical information and criteria used to guide approval decisions.

Provider Network Requirements
Requiring or encouraging members to use network providers enables plans to negotiate discounts on behalf of members, thus keeping costs down.

Member cost is greater for care received outside of the plan network, but the difference between benefits in and out of network varies by plan.
Traditional HMO plans require use of network providers in order for benefits to be paid.
HMO Point-of Service (POS) plans must cover certain services (defined by the plan) when received out of network.
PPO plans must cover all services when received out of network.
No health plan may require use of a network provider in an emergency situation.

Referrals to Specialists
Managed care plans may require members to see their PCP before seeing a specialist, so that the PCP may decide whether they can treat the condition themselves or whether specialty care is needed. A PCP can also make sure that the referral is made to a network specialist and make a recommendation for a particular physician.

Referral requirements are more common in HMOs than in PPOs. Most HMOs in North Carolina require PCP referrals.

Approved Service Areas for Licensed HMOs
Preferred Provider Organizations (PPOs)
A group of health care providers, each of whom agrees to offer services to a given employer or insurer at a lower cost in return for a stable volume of patients or other incentive(s)
Group (Contact employer to determine your status)

Insured
Group insurance programs designed to offer affordable health coverage to a natural group, such as employees of an employer or members of an association and their families. A single contract is provided for the entire group which outlines the standard benefits, terms and provisions that apply to all members of the group. Individual certificates are usually issued to the members to verify that they are covered.

ERISA
When an employer decides to fund and administer his/her own employee benefit plan instead of using outside sources. Employee benefit plans are regulated by the U.S. Government by means of the Employees' Retirement Income Security Act (ERISA) of 1974.

Small Group and Self-Employed
North Carolina's Small Employer Group Health Coverage Reform Act was enacted in 1992. The purposes of the Act were to promote the availability of accident and health insurance to small employers, to eliminate abusive rating and underwriting practices, and to improve the fairness of this marketplace.

Insurers are required to offer without regard to health status the Standard and Basic health plans to small groups and self employed individuals in order to sell coverage in the small group market. This includes coverage for all eligible employees and their dependents. The Department has designed and requires all insurers to offer the same benefits in the Standard and Basic health plans according to the type of the insurer. Therefore, benefits will be the same within each insurer type regardless of the insurance carrier.

All insurers who are actively marketing small group health insurance in North Carolina must quote a small group rate on all plans that the insurer offers in the small group market, if the small employer is within the insurer's service area. Further, the insurer may not refuse to issue the coverage to a small employer except for stated reasons, including when the group is outside the insurer's service area or when the group fails the insurer's participation or contribution requirements. This requirement does not apply to self employed individuals who have guaranteed access to the Standard and Basic plans only. Please remember that although a self employed individual may not be offered all plans an insurer is marketing in the small group market, he must at least be offered the Standard and Basic health plans.

The definition of small employer in North Carolina is any individual actively engaged in business that, on at least 50% of its working days during the preceding calendar, employed no more than 50 eligible employees, the majority of whom are employed within this State and is not formed primarily for insurance purposes.

The definition of a self employed individual is an individual or sole proprietor who derives a majority of his or her income from a trade or business carried on by the individual or sole proprietor which results in taxable income as indicated in IRS form 1040, Schedule C or F and which generated taxable income in one of the two previous years.

An insurer must confirm that an applicant is a small employer and/or a self-employed individual. Therefore, an insurer will most likely request appropriate tax forms and other information which will identify the number of eligible employees, where they are employed, and any affiliated employers during the application process and may refuse to issue coverage if proper proof is not provided.

Limited or Supplemental Health Insurance
Health Insurance designed to provide coverage for medical expenses not covered by the primary policy or by Medicare.

Dental
A type of health insurance sold on an individual or group basis that will provide benefits for care and treatment of the teeth and gums. Benefits vary from policy to policy as some may cover 100% of preventative care (such as semi-annual check-ups, fluoride treatments, etc.) while others may only cover a portion of preventative care. There is normally an annual benefit maximum for preventative care services. However, benefits for orthodontic procedures (e.g. braces, retainers, etc.) are normally extremely limited and have a lifetime benefit maximum.

Cancer
A form of health insurance that will only pay when the insured person is diagnosed with a covered cancer. The benefits may be paid as an indemnity amount (scheduled benefit rate) or based on the actual expenses incurred for the treatment. Benefits under these types of insurance plans are normally paid directly to the insured person in lieu of the medical provider. Insurance may be sold on an individual or group basis.

Accidental Death and Dismemberment
This type of insurance will provide benefits in the event death resulting from a covered accident. Further, benefits are paid if there is a loss of two limbs, or sight of both eyes. Reduced benefits are normally payable for loss of one limb or of sight in one eye as well as loss of a foot or hand.
This information provided by the North Carolina Department of Insurance.