Sep 13

If You Have Pre-Existing Medical Conditions, It Is Better to Get Group Insurance

If you have a pre-existing medical condition, you may be painfully aware of just how difficult it can be to find adequate health insurance. Many insurance companies will either deny people with existing medical conditions or impose long exclusion periods in which you will pay premiums without receiving any benefits. There are other options available, however. Many group plans do not discriminate based on your medical history; some, in fact, are designed specifically for those with pre-existing medical conditions.

If you can get a health insurance plan sponsored by your employer, this may be the best option. These group plans do not check your medical history and often provide competitive benefits at a highly discounted rate. If you are married and your employer does not offer insurance coverage, try to get on your spouse’s health plan if at all possible. If you belong to a union, guild, or other organization, you may be able to obtain health insurance through them. If you need to change or renew your plan after enrollment, rest assured that your right to coverage will be protected under HIPAA, the Health Insurance Portability and Accountability Act.

HIPAA will also prevent you from losing coverage if you find yourself unemployed. To be eligible for a HIPAA plan, you will need to have health insurance for at least 18 months prior to losing your health plan. The most recent insurance plan will need to be sponsored by an employer for you to qualify, and there must be no breaks in coverage greater than 63 days. To apply, first obtain a Certificate of Creditable Coverage from your last insurance company. By law in many states, insurance companies must offer a couple of their most popular plans as HIPAA plans once you show creditable coverage. Having this type of plan will allow a smooth transition to other group plans later on and will prevent you from suffering through an exclusion period.

High-risk insurance pools are currently available in all states. Some states offer their own high-risk insurance options, while others prefer to let the government set up Pre-Existing Condition Pools (PCIP). If you have been denied health insurance based on your medical history, you should qualify for one of these group plans. Be warned that although premiums are relatively affordable, you will need to pay a yearly deductible before receiving insurance benefits. A PCIP, while not the best option for everyone, is a good option for those who have no other choice.

If you need help with this, we can help. Please visit our website at and provide your contact information so we may respond to your request and guide you throughout the process.

Sep 11

Veterans Benefit Links

There are many benefits available to those who served in the military, many that veterans fail to take advantage of either because they are not aware the benefits exist or because they have no knowledge as to how to go about it or where to find the right form, and finally learning how to file.

Some may say that this was done by design to make up for funding limitations. This article is not intended to prove or disprove such allegations but one point is clear, don’t expect anyone to contact you or offer assistance unless you ask for it first. It is up to you to initiate the effort to obtain these benefits.

This article is intended to enlighten you (veterans) as to some of what is available as well as point you in the direction to seek out and obtain those benefits. As one veteran put it to me recently, “You performed your part for your country by placing your life on the line and now it is time for the country to fulfill its promise to you in return.”

Let us use the name John Doe for a real person who left the U.S. Army with service connected injuries years before computers, mass electronic storage devices or the Internet became household names. He applied for disability by writing down the dates and circumstances surrounding his in-service injuries and submitted a claim to the Veterans Administration expecting they would check his records, verify his inputs then award him for the damages incurred. Of course, they denied his claims, not because he wasn’t entitled to them, but because he had failed to follow proper procedure, probably the single most important reason given for denying claims. That’s when he learned he had the right to appeal and something more about the meaning of the term Nexus.

What is Nexus? In VA jargon it means a medical link or relationship between the in-service injury and a present disability, and is often described as a three-legged stool:

(1) An in-service documented injury or disease (condition),
(2) Medical evidence of a present condition,
(3) And a connection between the in-service condition and the present out-of-service condition, i.e., Nexus.

It would be many years later before Doe would learn more details, like a disability claim should be supported by a letter from a medical doctor, preferably board certified in the conditions listed in the claim. The doctor states that he or she has thoroughly reviewed all available and pertinent medical records, and this next part is critical, including not only “civilian” medical records but Service Medical Records as well. It is important to note that the VA follows an almost exact code when it comes to the wording used in these Nexus letters. The doctor states that based on his/her examination, the present condition is “due to” (100% due to) OR “more likely than not” (more than 50% likely) or “at least as likely as not” (50% likely) or “not at least as likely as not” (less than 50% likely) or “is not due to” (0% likely)… the in-service injury or exposure, and that he or she believes the existing condition and the in-service condition are connected.

When John Doe’s hand-written claim was denied back in those days without the Internet and computer based system, he wrote to the National Personnel Records Center (NPRC) asking for his medical records and was notified they did not exist. All your records, they claimed, had perished in the infamous fire that occurred in St. Louis in 1973. With that piece of information, any hope he had of ever filing a claim or an appeal went out the window.

Fast forward to 2004 when Doe learned from the Internet that it might be possible to reconstruct his lost medical records. One reply to the many inquiries he sent out came from NPRC, the ones who told him his records had perished in the fire. This time, decades after the fact, they wrote to tell him: “Good news! We are happy to inform you that your military record was not affected by the fire…” Finally, he could file his appeal – but not retroactively. Those prior decades during which they kept telling him his files had burned were lost years when he could have been receiving compensation. It was as though he had left the Army in 2005 instead of 1962.

After years of frustration, with no one helping him and not knowing where to start, John Doe began a new odyssey of learning where to go and what to do, and guess what? After all those years, he’s still learning. Only a few months ago he discovered he would have been entitled to a higher disability payment each month because he has a wife but failed to report her. Buried in reams of paperwork the VA sent was a line telling him they had him listed as a single man. Either he never saw the part that listed him as single or he did not know its meaning in terms of dollars, and even if he did see it there, how was he to know that being married entitled me to about sixty more dollars a month? Either way, the VA was not obligated to go back and reimburse him for the lost payments. The point of this story is that if you don’t seek out these benefits, you won’t get them and then some day when you do discover they exist, the VA won’t necessarily make them retroactive to make up for your past mistake or failure to apply.

So, as you can see, these and many more benefits do exist for veterans but it’s up to you to find out which they are and if you are entitled to them. Perhaps the best place to start is by finding an advocate. There are plenty of places to seek out an advocate who will guide you through the maze of obstacles and educate you on just what is available to you: the DAV, AMVETS, VFW, American Legion, Blinded Veterans Association, and local county service officers, to list a few – and they are free.

Included below is a link that you can click on to take you to a long list of sites that describe veteran benefits. Some sites on this list have been removed and others replaced but I ran a test of each site on 3/8/2010 and found that around 70% were still active. I cannot list the hyperlinks here for you because I am restricted from including more than four in any one article included herein. But if you follow the above link that I included below as “Links for Veterans,” you can get to each one that I have listed here as active.

A sampling of a few important sites are described briefly below:

1. Board of Veterans Appeals: The Board of Veterans’ Appeals (also known as “BVA” or “the Board”) is a part of the VA, located in Washington, D.C. Members of the Board review benefit claims made by local VA offices then issue decision on appeals.

2. Veterans Benefits and General Information: This site lists all benefits and provides links to each, including Education, Home Loans, Compensation and Pension, Survivor’s Benefits, Vocational Rehab, Life Insurance. Also benefits for veterans returning from Operations Enduring Freedom and Iraqi Freedom.

3. Veterans Benefits Administration: This is where you can look up the Code of Federal Regulations (38 CFR).

4. Veterans Benefits Administration – 38CFR Book C: Schedule for Rating Disabilities, an important reference when filing a claim or making an appeal.

5. GI Bill Website: The Post 9/11 GI Bill provides financial support for education and housing to individuals with at least 90 days of aggregate service on or after September 11, 2001, or individuals discharged with a service-connected disability after 30 days.

Below is a list of the 70% that tested Active on “Links for Veterans.” You can go to the actual list by clicking on the following link:

  • Appeals
  • Board of Veteran’s Appeals
  • CARES Commission
  • Center for Minority Veterans
  • Center for Women Veterans
  • Compensation Rate Table
  • Department of Veterans Affairs Home Page
  • Directory of Veterans Service Organizations
  • Disability Examination Worksheets Index, Comp
  • Electronic Code of Federal Regulations
  • Emergency, Non-emergency, and Fee Basis Care
  • Environmental Agents
  • Federal Benefits for Veterans and Dependants 2005
  • Forms and Records Request:
  • Geriatrics and Extended Care
  • GI Bill Website
  • GI Bill Post 9/11
  • Guide to Gulf War Veteran’s Health
  • Gulf War Subject Index
  • Gulf War Veteran’s Illnesses Q&As
  • Homeless Veterans
  • Index to Disability Examination Worksheets C&P exams
  • M21-1 Table of Contents
  • Mental Disorders, Schedule of Ratings
  • Mental Health Program Guidelines
  • My Health eVet: NASDVA.COM National Association of State Directors
  • Neurological Conditions and Convulsive Disorders, Schedule of Ratings
  • OMI (Office of Medical Inspector)
  • Online VA Form 10-10EZ
  • Parkinson’s Disease and Related Neurodegenerative Disorders
  • Policy Manual Index
  • Prosthetics Eligibility
  • Public Health and Environmental Hazards Home Page
  • Publications Manuals: Records Center and Vault Homepage
  • Records Center and Vault Site Ma
  • Research Advisory Committee on Gulf War Veterans Illnesses April 11, 2002
  • Pensions, Bonuses & Veterans Relief (also 3.317 Compensation for certain disabilities due to undiagnosed illnesses found here): U.S. Court of Appeals for Veterans Claims
  • VA Best Practice Manual for Posttraumatic Stress Disorder (PTSD)
  • VA Loan Lending Limits and Jumbo Loans
  • VA National Hepatitis C Progra
  • VA Office of Research and Develompment:
  • VA Trainee Pocket Card on Gulf War
  • Vet Center Eligibility – Readjustment Counseling Service
  • Veterans Benefits Administration Main Web Page
  • Veterans Benefits Administration – 38CFR Book C
  • Veterans Legal and Benefits Information
  • VHA Forms, Publications, Manuals
  • VHA Public Health Strategic Health Care Group Home Page
  • Vocational Rehabilitation
  • VONAPP online
  • WARMS – 38 CFR Book C
  • War-Related Illness and Injury Study Center – New Jersey
  • Welcome to the GI Bill Web Site


Sep 04

Unemployed – How to Respond When Benefit Checks Lapse

Twenty-six weeks of unemployment benefits is just not long enough for a rehire in these severe recessionary times. Unfortunately, millions of Americans are learning that stark truth. Job hunts are taking an historically unprecedented amount of time. Though the checks have quit coming, you still have ways to keep shelter (your home) and foodstuffs in the pantry. The odd thing about these extra benefits that people can apply for has to do with pride.

Some Americans have looked down their nose at folks who sought assistance under these programs. Other Americans have felt too proud to avail themselves of these benefits. This well-meaning country attached some funds from each American hard-earned salary to protect the unfortunate. These programs exist for every American. It is foolish to forgo programs that were meant as safety nets for anybody in need.

One: Extensions

Workers out of work may be approved for a compensation extension. Extensions are not uncommon. In fact, these tough times have pushed government administrators to automatically extend all benefits from time to time. The higher the jobless rates, the better your chances for an extension.

Two: T.A.N.F.

Temporary Assistance for Needy Families (TANF) is a program that used to be called public assistance or welfare. Federally funded, this program can help you pay for fact-of-life expediencies. Food stamps and even help with your job search are among the benefits. To be eligible for TANF, you will have to meet certain benchmarks. It is true that TANF is funded by the federal government, but each state is allowed to administer the disbursement of food stamps and payouts. So benefits can vary somewhat from state to state.

Three: S.N.A.P.

Supplemental Nutrition Assistance Program (SNAP) oversees the parceling out of food stamp benefits for folks all over the nation. Qualifying for SNAP will allow you food stamps for up to twenty-six weeks. If that is not enough time, you can re-apply and get extensions that will last from 13-20 weeks. Your income, or lack thereof, and the number in your household will determine the monetary amount of assistance you will receive.

Nowadays, food stamp benefits come in the form of an EBT card. Monthly money will be automatically and electronically sent directly to your EBT card account. You use it much as you would a debit card. Restrictions apply regarding your purchases. Household items, like paper cups or floor wax, or pre-prepared foods from the deli such as salads or birthday cakes, are not usually covered with an EBT card.

Four: Medicaid

Low income people who cannot afford traditional benefit from a federal program termed Medicaid. Your health care provider is paid directly from the program. If you are eligible for Medicaid, in some states you may have to cover some of your health care costs. In other states, the program can cover one-hundred percent of the medical costs. Also, if you do not qualify, your children may. Probably the best approach is to apply and see who in your household might be covered.

Five: H.E.A.P.

Home Energy Assistance Program (H.E.A.P.) lends a hand to households experiencing financial problems who need energy bill assistance. Once you qualify, you will receive help paying your winter heating bills and your summer air-cooling bills.

There is certainly no need to feel bad about applying for these benefits. You paid hard-earned money in taxes to provide these benefits for others, it is just that now you are one of the others. No embarrassment needed or wanted.

Aug 28

Coverage Options For Medicare Eligible Individuals

People with Medicare can obtain their medical care through original Medicare or the Medicare Advantage Program (Part C). Medicare Advantage Plans consist of HMO, PPO, Private Fee for Service Plans and Special Needs Plans. Of the more than 10 million individuals enrolled in Medicare Advantage Plans, the majority are enrolled in HMO’s (Health Maintenance Organizations) which have been available since the 1980′s.

To help your parents (or you) make an informed decision, they need to understand how these plans work, and then decide which plan is right for them. The following is a brief description of each of the plan types.

Original Medicare
If an individual elects to go with traditional fee for service Medicare, they can generally use any doctor or hospital that accepts Medicare assignment anywhere within the United States. However, Medicare does have deductibles, copays and cost sharing requirements that can play havoc with budgets. To help pay these additional out of pocket expenses, many individuals purchase Medigap or Medicare supplement policies.

Medicare Advantage Plans (Part C)
If you opt to go with a Medicare Advantage Plan, you actually trade your traditional Medicare benefits for these plans. Many of the Medicare Advantage Plans are offered to eligible individuals at little or no cost other than continued payment of their Part B monthly premiums.

Medicare HMO’s (Health Maintenance Organizations)
These plans cover the same physician and hospital costs as traditional Medicare, but usually with lower out of pocket costs. HMO’s are attractive to Medicare eligible individuals because they often provide extra benefits like eyeglasses, hearing aids, and dental benefits which are not covered by traditional Medicare.

Individuals considering a Medicare HMO should be aware that they can only receive medical services from providers who are part of the HMO’s network of contracted providers. The HMO usually requires that an individual joining their plan select a primary care physician from those who participate in their network. This primary care physician would then be responsible for all medical care including referrals to a specialist and admittance to a hospital. The HMO will not pay for unauthorized visits to specialists nor non-emergency care received outside the HMO’s service area or visits to non-network physicians.

Medicare PPO’s (Preferred Provider Organizations)
These plans are private healthcare plans like HMO’s. However, PPO’s and HMO’s do differ into two very important areas. First, Medicare PPO’s do cover eligible medical care services obtained from doctors and hospitals outside the PPO network. And, second, Medicare PPO’s do not usually require that you obtain an authorization before seeking care from a specialist.

Regional PPO’s are available in many areas of the country. These plans serve large geographic areas and must offer the same premium costs and plan benefits to all individuals residing in these areas. Medicare PPO’s cover the same types of medical expenses that traditional Medicare does. In addition, Medicare PPO’s commonly include a prescription drug benefit. Unlike traditional Medicare, Medicare PPO’s have an annual out of pocket limit for benefits covered under Parts A and B of Medicare. The out of pocket limit caps the amount an individual can spend on covered medical expenses in a calendar year. As with any PPO program, when an individual uses a non-contracted provider for covered services, they will pay more out of their pocket.

Private Fee for Service (PFFS) plans
These plans are available to Medicare beneficiaries in exchange for their traditional Medicare Benefits. PFFS don’t have a formal network of doctors and hospitals to choose from and not all doctors or hospitals are willing to provide medical services to participants in these types of plans. If an individual is considering enrollment, it is wise to check with their doctor and local hospitals to make sure that they will accept the plan’s payment for services before enrolling. Also, the enrollee should thoroughly understand the benefits of a fee for service plan because the fee for service plans decide how much they will pay for Medicare covered services and may charge a higher cost sharing percentage than traditional Medicare. Private fee for service plans may include a prescription drug benefit. If they do not, the enrollee is free to join a Medicare stand alone prescription drug plan.

Special Needs Plans (SNP)
These plans are private plans that provide benefits to Medicare beneficiaries, including prescription drug coverage, who need additional help paying for their medical benefits. These would include individuals who qualify for both Medicare and Medicaid (MediCal in California), those residing in long term care facilities, and those with chronic or disabling medical conditions.

Medicare Prescription Drug Plans (Part D)
Prescription drug plans are available to all Medicare eligible persons regardless of medical history or income levels. When a person first qualifies for Medicare, their initial enrollment period begins three months before their 65th birthday, includes their birth month, and ends three months after their birth month. Otherwise, the annual open enrollment period for prescription drug plans runs from November 15th thru December 31st, with the coverage commencing on the following January 1st.

Medicare drug plans are designed to reduce drug costs for enrollees and protect against catastrophic drug costs. However, there is a monthly cost for these plans. In addition to a monthly premium, the covered individual is required to pay a percentage of the cost of the medications (or a copay) and Medicare pays part of the cost. Costs for a plan will vary depending on the medications taken and the type of plan selected. At a minimum, the plans available must provide a “standard” level of coverage.

For 2010, a standard prescription drug plan will have the following costs:
• A monthly premium which varies from approximately $24 per month to in excess of $100 depending upon the plan selected and medications taken.
• An annual deductible equal to the first $310 worth of prescription drugs.

After the annual deductible has been satisfied, the insured will pay the following amounts for the remainder of 2010:
• 25% of the cost for covered medications from $310 up to $2830 in charges, (the plan pays the other 75% of these costs); then
• 100% of the next $3842.50 in total drug charges (often called the donut hole or coverage gap); then
• After exceeding the annual of pocket limit of $4550, 5% of your drug costs or a copay of $2.50 or $6.30, whichever is greater for the rest of the current calendar year.

This describes a “Standard Plan.” Many of the prescription drug vendors do offer better benefit plans which forego the plan deductible and substitute copays instead of the 25% coinsurance. Generic medications are available for substantially less than brand names with these plans.

There is a penalty of 1% per month, using the average national premium, for non-enrollment/late enrollment, which is assessed for as long as they remain enrolled in the plan.

This has been just a brief overview of the benefits available to Medicare eligible individuals. For more detailed information, please consult the Medicare handbook, Medicare & You. The handbook is available by contacting Medicare at 1-800-MEDICARE1-800-MEDICARE or visiting the Medicare website at

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