Standard Operational Procedures

Email: Support@SaintFlorence.com

Phone: (201) 639-3655 

Fax: (201) 639-3655 

Address: 623 Eagle Rock Ave, Suite 4, West Orange, NJ 07052

Website: www.SaintFlorence.com

Medical Insurance

- Medicare Advantage Plans (MAPD)

- Medicare Supplemental Plans 

- Prescription Drug Plans (PDP)

- Affordable Care Act (ACA)/ GetCovered/ Marketplace. 

- Dental & Vision Plans

Life Insurance

- Indexed Universal Life Insurance

- Children Whole Life Insurance

- Final Expenses / Burial Insurance

- Term Life Insurance

- Guaranteed Issued Life Insurance

- Many others...

Employer Sponsored Insurance

- Group Voluntary Whole Life

- Group Health Insurance

- Group Disability Insurance

Retirement Plans

- Annuities

Health Insurance:

- AARP

- United Healthcare

- Brave Health

- Horizon Blue Cross Blue Shield

- Humana

- Aetna

- Wellcare / Fidelis

- Wellpoint / Amerigroup

- Anthem

- Cigna

Life Insurance

- Mutual of Omaha

- Gerber Life

- MassMutual

- National Life

- Transamerica

- Aflac

- CSA Life

Annuities

- AIG

- CSA Life

- Nationwide

- US Life

Medicaid (ABD)

State: NJ FamilyCare

Income Limit:
Single: $1,255 | Assets Limit: $4,000
Married: $1,704 | Assets Limit: $6,000

Benefits: Adult daycare services, transportation, over-the-counter benefits, dual eligibility, money for groceries, payment of light and phone bills, and more.

Managed Long-Term Social Services (MLTSS) [Medicaid Based on Health]
State: NJ FamilyCare

Income Limit:
Individual: $2,829 | Assets Limit: $2,000

Benefits: Adult daycare services, transportation, over-the-counter benefits, dual eligibility, money for groceries, payment of light and phone bills, and more. The biggest difference between MLTSS and Medicaid is that MLTSS has a higher income limit, requires a Physician Certification Form, and provides more comprehensive Medicaid coverage since it is based on health rather than just income.

Medicare Savings Program
State: NJ Save

Income Limit:
Single: $1,506 | Assets Limit: $9,430
Married: $2,044 | Assets Limit: $14,130

Benefits: Once approved, the applicant can have the state pay their Part B premium (usually $174.90). In certain cases, the state may reimburse the last 5 months of the Part B premium, approximately $874.

Pharmaceutical Assistance for the Aged & Disabled (PAAD)

State: NJ Save

Income Limit:
Single: $4,345 | Assets Limit: No Cap
Married: $4,934 | Assets Limit: No Cap

Benefits: It helps pay up to $48 of the monthly premium or penalty related to prescription drug coverage. It also covers the entire deductible and lowers copayments at the pharmacy.

Senior Gold

State: NJ Save

Income Limit:
Single: $5,178 | Assets Limit: No Cap
Married: $5,767 | Assets Limit: No Cap

Benefits: It covers the entire prescription drug deductible and lowers copayments at the pharmacy.

Low-Income Subsidies (LIS) –

Federal- SSA.gov/Extrahelp

Income Limit:
Single: $1,903 | Assets Limit: $17,220
Married: $2,575 | Assets Limit: $34,360

Benefits: It helps pay up to $48 of the monthly premium or penalty related to prescription drug coverage. It also covers the entire deductible and lowers copayments at the pharmacy.

REQUIRED DOCUMENTS

(For all applications except LIS)

• Proof of Address
• Proof of Income
• Picture ID
• Medicare, Medicaid, and Other Health Insurance Cards
• Bank Statements (Last 3 Months)
• Birth Certificate (or US Passport, or Green Card)
• Life Insurance Policy (if any)
• Physician Certification Form (only for MLTSS)
• The state may require 5 years' worth of bank statements post-application for MLTSS.

The Late Enrollment Penalty (LEP) is a surcharge applied to individuals who do not sign up for Medicare Part B (Medical Insurance) or Part D (Prescription Drug Coverage) when they first become eligible, and who do not have qualifying coverage elsewhere. This penalty is intended to encourage timely enrollment and avoid gaps in coverage.

Medicare Part B Late Enrollment Penalty

If you don’t sign up for Medicare Part B when you’re first eligible (usually when you turn 65), and you don’t qualify for a Special Enrollment Period (SEP), you could face a late enrollment penalty.

• How the Penalty is Calculated: The penalty is an additional 10% of the Part B premium for each full 12-month period that you could have had Part B but didn’t enroll. For example, if you delayed enrollment for two years, your monthly premium would include a 20% penalty.
• How Long the Penalty Lasts: This penalty is lifetime—you will have to pay the increased premium as long as you have Part B.

Medicare Part D Late Enrollment Penalty

If you don’t sign up for a Medicare Part D plan (prescription drug coverage) when you’re first eligible and don’t have creditable prescription drug coverage (coverage that is at least as good as Medicare’s), you may face a late enrollment penalty.

• How the Penalty is Calculated: The penalty is 1% of the "national base beneficiary premium" for every full month that you were without creditable drug coverage. The national base beneficiary premium may change each year, and the penalty is added to your monthly Part D premium.
  
  • For example, if you went 15 months without drug coverage, your penalty would be 15% of the national base premium. If the base premium is $48, your penalty would be approximately $7.20, which is added to your monthly premium.
• How Long the Penalty Lasts: Like the Part B penalty, the Part D penalty is lifetime and must be paid as long as you have a Part D plan.

Exceptions to the Late Enrollment Penalty

There are certain situations where you may avoid the late enrollment penalty:

• Special Enrollment Period (SEP): If you delay Medicare because you have other creditable health coverage (such as employer-sponsored insurance), you may qualify for a SEP once that coverage ends, allowing you to enroll without a penalty.
• Extra Help Program: Individuals who qualify for Extra Help (a federal assistance program for low-income individuals) may not have to pay a late enrollment penalty for Medicare Part D.

How to Avoid the Penalty

• Enroll in Medicare Part B and Part D during your Initial Enrollment Period (IEP), which starts three months before the month you turn 65 and ends three months after.
• If you have other insurance, ensure it is considered creditable coverage to avoid future penalties.
• If you miss the IEP, make sure to enroll as soon as possible during the General Enrollment Period (GEP) (January 1 – March 31) to minimize the penalty.

The Late Enrollment Penalty can be costly over time, so it's important to understand your eligibility and enrollment windows to avoid these additional charges.

Also, EXTRA HELP can help pay for this penalty. 

1. Medicare: A federal health insurance program primarily for people aged 65 and older, or younger people with certain disabilities.
2. Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.
3. Part B (Medical Insurance): Covers doctor visits, outpatient care, preventive services, and some home health care.
4. Part C (Medicare Advantage): Private insurance plans that offer all Medicare Part A and Part B benefits, often with additional services like vision, dental, or prescription drug coverage.
5. Part D (Prescription Drug Coverage): Helps pay for prescription drugs. Available through private insurance companies approved by Medicare.
6. Medigap (Medicare Supplement Insurance): A private insurance policy that helps cover some of the costs that Original Medicare doesn't cover, like copayments, coinsurance, and deductibles.
7. Initial Enrollment Period (IEP): The 7-month period around your 65th birthday when you can first sign up for Medicare (3 months before, your birthday month, and 3 months after).
8. General Enrollment Period (GEP): The time between January 1 and March 31 each year when you can sign up for Medicare if you missed your initial enrollment period.
9. Special Enrollment Period (SEP): A specific time when you can enroll in Medicare after your IEP ends, usually because of circumstances like losing employer-sponsored health insurance.
10. Creditable Coverage: Health insurance (like employer plans) that is considered at least as good as Medicare’s coverage. Having it allows you to delay Medicare enrollment without penalties.
11. Late Enrollment Penalty (LEP): A penalty for not enrolling in Medicare Part B or Part D when first eligible, unless you have creditable coverage. The penalty lasts for as long as you have Medicare.
12. Medicare Savings Program (MSP): State-run programs that help pay Medicare premiums and sometimes other costs for low-income individuals.
13. Extra Help: A federal program that helps low-income individuals pay for Medicare Part D prescription drug costs.
14. Dual Eligibility: When someone qualifies for both Medicare and Medicaid (another federal-state health program for low-income people), allowing for more comprehensive coverage.
15. Medicare Advantage Plan (MA): See Part C.
16. Medicare Summary Notice (MSN): A notice sent by Medicare detailing services and supplies that were billed to Medicare and what Medicare paid for.
17. Skilled Nursing Facility (SNF): A facility that provides nursing and rehabilitation services after a hospital stay, typically covered under Medicare Part A for a limited time.
18. Physician Certification Form (MLTSS): A form required for Medicaid's Managed Long-Term Services and Supports program, confirming that a patient needs long-term services based on their health.

1. Medicaid: A federal and state program that provides health coverage to eligible low-income individuals, families, and certain groups like the elderly and disabled. Each state runs its own Medicaid program within federal guidelines.
2. Medicaid Expansion: Under the Affordable Care Act, states can expand Medicaid coverage to include more low-income individuals, typically adults under 65 with incomes up to 138% of the federal poverty level.
3. Federal Poverty Level (FPL): A measure of income issued annually by the Department of Health and Human Services (HHS) used to determine eligibility for Medicaid and other assistance programs.
4. Modified Adjusted Gross Income (MAGI): A method used to determine financial eligibility for Medicaid and certain other health programs based on adjusted gross income, with some additional modifications.
5. Dual Eligibility: When someone qualifies for both Medicaid and Medicare. Dual eligibles typically have low income and limited resources, and they receive comprehensive benefits from both programs.
6. Managed Care Organization (MCO): A private company contracted by state Medicaid programs to manage the delivery of healthcare services to Medicaid enrollees. MCOs help control costs and improve access to care.
7. Fee-for-Service (FFS): A Medicaid payment model in which healthcare providers are paid for each service they provide, rather than receiving a set amount per enrollee.
8. Children’s Health Insurance Program (CHIP): A program closely related to Medicaid that provides low-cost health coverage to children in families who earn too much to qualify for Medicaid but cannot afford private insurance.
9. Eligibility Verification System (EVS): A system that Medicaid providers use to verify a patient’s Medicaid eligibility before providing services.
10. Asset Limit: The maximum value of assets (like savings, investments, and property) that an individual or family can have and still qualify for Medicaid. Asset limits vary by state and by the specific Medicaid program.
11. Income Limit: The maximum income an individual or family can earn to qualify for Medicaid. This limit varies based on the state and the type of Medicaid program.
12. Spend Down: A process by which individuals with high medical expenses can "spend down" their income to qualify for Medicaid, particularly in states where Medicaid requires income to be below certain levels.
13. Medicaid Waivers: Special programs that allow states to use Medicaid funds in innovative ways, often to provide services in home- and community-based settings instead of institutional care. Popular waivers include 1915(c) and 1115 waivers.
14. 1915(c) Waiver (Home and Community-Based Services Waiver): Allows states to provide long-term care services to Medicaid beneficiaries in their homes or communities, rather than institutional settings like nursing homes.
15. 1115 Waiver: A waiver that allows states to test new or innovative ways of delivering Medicaid services, such as expanding eligibility, offering different types of benefits, or testing alternative payment models.
16. Mandatory Medicaid Benefits: Benefits that every state’s Medicaid program must cover, including hospital services, physician services, lab tests, and X-rays.
17. Optional Medicaid Benefits: Benefits that states can choose to provide through their Medicaid programs, such as prescription drugs, dental services, and physical therapy.
18. Long-Term Services and Supports (LTSS): A range of health and personal care services for individuals who need help with everyday activities due to aging, chronic illness, or disability. LTSS can be provided at home, in community settings, or in institutions like nursing homes.
19. Medically Needy: Medicaid eligibility category for individuals whose income is above the Medicaid limit but have high medical expenses that "spend down" their income to a qualifying level.
20. Medicaid Asset Recovery: A process where Medicaid seeks repayment for certain services from the estates of deceased Medicaid beneficiaries, particularly for long-term care services provided after age 55.
21. Pharmaceutical Assistance to the Aged and Disabled (PAAD): A state program (in some states like New Jersey) that helps Medicaid beneficiaries pay for prescription drugs.
22. Medicaid Managed Long-Term Services and Supports (MLTSS): A Medicaid program designed to provide long-term services, such as nursing home care or in-home services, through managed care plans. MLTSS is typically for individuals who need help due to health conditions or disabilities.
23. State Medicaid Agency: The state government office responsible for administering Medicaid programs and ensuring compliance with federal regulations.
24. Estate Recovery: A policy that allows states to recover costs of Medicaid services from the estates of Medicaid beneficiaries after their death, typically for services provided after age 55 or for those in long-term care.
25. Medicaid Look-Back Period: The period during which Medicaid reviews an applicant's financial transactions to ensure they haven't transferred assets to qualify for Medicaid. For long-term care services, this period is typically five years.
26. Institutional Medicaid: Medicaid coverage for individuals living in institutional settings such as nursing homes or hospitals. Eligibility often depends on income, assets, and medical need.
27. Disproportionate Share Hospital (DSH) Payments: Payments made to hospitals that serve a large number of Medicaid and uninsured patients to help cover the cost of care.
28. Medicaid Expansion Adults: Adults who gained eligibility for Medicaid under the expansion option provided by the Affordable Care Act, typically for individuals earning up to 138% of the federal poverty level.

1. Life Insurance: A contract between an individual and an insurance company, where the company pays a death benefit to beneficiaries upon the insured person's death.
2. Term Life Insurance: Life insurance that provides coverage for a specific period (e.g., 10, 20, or 30 years). If the insured dies during that time, the beneficiary receives the payout.
3. Whole Life Insurance: A type of permanent life insurance that provides lifelong coverage and includes a savings component (cash value) that grows over time.
4. Universal Life Insurance (UL): A type of permanent life insurance that offers flexibility in premium payments and death benefits, as well as a cash value component.
5. Cash Value: The savings component of a permanent life insurance policy that grows over time and can be borrowed against or withdrawn.
6. Death Benefit: The amount of money paid out to the beneficiaries upon the insured person's death.
7. Beneficiary: The person or people designated to receive the death benefit from a life insurance policy.
8. Premium: The payment made to an insurance company to maintain coverage.
9. Policyholder: The individual who owns the life insurance policy and pays the premiums.
10. Insured: The person whose life is covered by the insurance policy.
11. Rider: An add-on to a life insurance policy that provides additional benefits or coverage, such as disability income or accelerated death benefits.
12. Accelerated Death Benefit (ADB): A rider that allows the insured to access part of their life insurance death benefit if they are diagnosed with a terminal illness.
13. Guaranteed Issue Life Insurance: A type of life insurance policy that doesn’t require a medical exam and is typically available to people with health issues or the elderly.
14. Simplified Issue Life Insurance: A policy that requires answering a few health-related questions but no medical exam.
15. Underwriting: The process an insurance company uses to assess the risk of insuring someone and determining premiums based on factors like age, health, and lifestyle.
16. Contestability Period: The first two years of a life insurance policy during which the insurance company can investigate and deny claims due to fraud or misrepresentation.
17. Lapse: When a life insurance policy is terminated because the policyholder failed to pay premiums.
18. Cash Surrender Value: The amount of money available to a policyholder if they cancel a permanent life insurance policy before death.
19. Non-Forfeiture Options: Options available to a policyholder when they stop paying premiums on a permanent life insurance policy, such as reduced coverage or converting to term insurance.
20. Return of Premium (ROP): A rider that refunds all or part of the premiums paid if the insured outlives the term of a term life insurance policy.

1. Premium: The amount of money you pay to an insurance company, typically monthly or annually, to keep your insurance policy active.
2. Deductible: The amount of money you must pay out-of-pocket for covered services before your insurance starts paying. For example, if your deductible is $1,000, you need to pay that amount before your insurance covers expenses.
3. Copayment (Copay): A fixed amount you pay for a covered health service, such as a doctor's visit or prescription, after you've met your deductible. For example, you may have a $30 copay for a doctor’s visit.
4. Coinsurance: The percentage of costs you share with your insurance company after you’ve met your deductible. For example, if your plan has 20% coinsurance, you pay 20% of covered services, and your insurance pays the remaining 80%.
5. Out-of-Pocket Maximum: The most you’ll have to pay for covered services in a policy period (usually one year). Once you reach this limit, your insurance company pays 100% of the costs for covered services. This includes deductibles, copayments, and coinsurance.
6. Exclusion: Specific conditions, treatments, or services that your insurance policy does not cover. You are responsible for all costs associated with exclusions.
7. Network: A group of doctors, hospitals, and other healthcare providers contracted with your insurance company to provide services at lower rates. Using "in-network" providers usually costs less than going "out-of-network."
8. Out-of-Network: Healthcare providers or services that are not contracted with your insurance plan. Costs are usually higher for out-of-network services, or they may not be covered at all.
9. In-Network: Healthcare providers or services that are contracted with your insurance plan to offer services at discounted rates. Using in-network providers usually costs less than out-of-network providers.
10. Claim: A formal request for your insurance company to pay for a covered healthcare service or expense.
11. Explanation of Benefits (EOB): A statement from your insurance company explaining what services were covered, what the insurer paid, and what you owe after a claim is processed.
12. Policyholder: The person who owns the insurance policy and is responsible for paying premiums.
13. Beneficiary: The person or people designated to receive the benefit (such as a death benefit for life insurance) when a claim is made.
14. Underwriting: The process by which an insurance company evaluates the risk of insuring someone and determines the premium amount based on factors like age, health, lifestyle, etc.
15. Grace Period: The time after a missed premium payment during which you can still pay without losing coverage. It typically lasts 30 to 60 days, depending on the insurance policy.
16. Rider: An optional add-on to an insurance policy that provides additional benefits or coverage, such as a waiver of premium for disability or accidental death benefit.
17. Pre-existing Condition: A health condition that you had before the start of your health insurance coverage. Some policies exclude coverage for pre-existing conditions, while others (especially under the Affordable Care Act) must cover them.
18. HMO (Health Maintenance Organization): A type of health insurance plan that requires you to use doctors and hospitals within its network and usually requires referrals to see specialists. It tends to have lower premiums and out-of-pocket costs but less flexibility.
19. PPO (Preferred Provider Organization): A type of health insurance plan that offers more flexibility in choosing doctors and hospitals, including out-of-network providers, though using in-network providers usually costs less.
20. EPO (Exclusive Provider Organization): A type of health insurance plan where you must use the network’s providers for all non-emergency care. There is no coverage for out-of-network services except in emergencies.
21. POS (Point of Service): A type of health insurance plan that combines features of HMO and PPO plans, requiring you to choose a primary care doctor but allowing you to see out-of-network providers at a higher cost.
22. Term Life Insurance: A type of life insurance that provides coverage for a specific period (e.g., 10, 20, or 30 years). If the insured dies within the term, the beneficiary receives the death benefit.
23. Whole Life Insurance: A type of permanent life insurance that provides lifelong coverage and includes a savings component (cash value) that grows over time.
24. Universal Life Insurance (UL): A type of permanent life insurance that offers flexible premiums, death benefits, and a cash value component that grows based on investments.
25. Cash Value: The savings component of permanent life insurance (e.g., whole or universal life) that accumulates over time and can be borrowed against or withdrawn.
26. Guaranteed Issue Life Insurance: Life insurance that does not require a medical exam, typically used by individuals who have difficulty qualifying for other types of life insurance due to health conditions.
27. Simplified Issue Life Insurance: A type of life insurance that only requires answering a few health-related questions without a medical exam.
28. Death Benefit: The amount of money the insurance company pays to beneficiaries upon the insured person's death.
29. Contestability Period: The first two years after a life insurance policy is issued during which the insurer can deny a claim if the applicant is found to have provided false information.
30. Accelerated Death Benefit (ADB): A rider that allows policyholders to access a portion of their life insurance death benefit early if diagnosed with a terminal illness.
31. Return of Premium (ROP): A feature or rider in term life insurance policies that returns the paid premiums to the policyholder if they outlive the policy term.
32. COBRA (Consolidated Omnibus Budget Reconciliation Act): A federal law that allows individuals to continue their employer-provided health insurance after losing their job, typically for up to 18 months, by paying the full premium.
33. Medicaid: A state and federal program providing healthcare coverage to low-income individuals and families.
34. Medicare: A federal health insurance program for people aged 65 and older, and younger people with certain disabilities.
35. Open Enrollment Period: The yearly period when you can sign up for or make changes to your health insurance plan. For Medicare, this typically occurs from October 15 to December 7.
36. Guaranteed Issue: A feature of some insurance policies (like Medigap) that requires insurers to offer coverage regardless of health status, typically during specific periods like when you first enroll in Medicare.
37. Provider: Any healthcare professional or facility (doctor, hospital, clinic) that provides healthcare services.
38. Out-of-Pocket Costs: Any healthcare expenses that you must pay yourself, including deductibles, copayments, and coinsurance, until you reach your out-of-pocket maximum.

1. Centers for Medicare & Medicaid Services (CMS): The federal agency within the Department of Health and Human Services (HHS) that oversees Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). CMS sets rules and regulations for Medicare Advantage and Part D plans.
2. Scope of Appointment (SOA): A required document in Medicare sales that outlines the topics a Medicare beneficiary has agreed to discuss with a licensed agent. It ensures that no other services or plans are discussed beyond what is pre-approved, preventing misleading or unauthorized marketing practices.
3. Health Risk Assessment (HRA): A questionnaire used by Medicare Advantage plans to assess the health status of enrollees. The information gathered helps identify health needs, coordinate care, and determine eligibility for certain benefits or care management programs.
4. Medicare Marketing Guidelines: Rules set by CMS to ensure that marketing activities by Medicare Advantage and Part D plan providers (and their agents) are accurate, fair, and not misleading. Agents must adhere to these guidelines when promoting plans to beneficiaries.
5. Special Enrollment Period (SEP): A time outside of the regular Medicare enrollment periods when individuals can sign up for Medicare or change plans due to specific life events. SEPs allow flexibility for those who experience changes such as loss of employer coverage, moving out of a plan’s service area, or becoming eligible for Medicaid.
   Common SEPs include:
   
   • Loss of Employer Group Coverage: If a beneficiary loses health coverage from their employer or union, they can enroll in Medicare or switch plans during this SEP.
   • Moving to a New Service Area: Beneficiaries who move out of their Medicare Advantage or Part D plan's service area can use this SEP to switch plans.
   • Dual Eligibility: Individuals eligible for both Medicare and Medicaid can change plans during certain times of the year without waiting for the annual enrollment period.
   • Extra Help Eligibility: If someone qualifies for Medicare's Extra Help program (low-income subsidy), they can use an SEP to switch plans.
   • Institutionalized SEP: Beneficiaries entering or leaving long-term care facilities (such as nursing homes) have a SEP to enroll in or change their Medicare Advantage or Part D plan.
   • Five-Star SEP: Beneficiaries may switch to a Medicare Advantage or Part D plan with a 5-star rating once per year.

1. Annual Enrollment Period (AEP): A set period (October 15 to December 7) when all Medicare beneficiaries can review, join, switch, or drop their Medicare Advantage or Part D plans for the following year. Changes take effect on January 1.
2. Initial Enrollment Period (IEP): The seven-month period when someone first becomes eligible for Medicare (three months before turning 65, the month of their 65th birthday, and three months after). This is when a person can enroll in Medicare Part A and Part B or choose a Medicare Advantage plan.
3. Medicare Advantage Open Enrollment Period (MA-OEP): A period from January 1 to March 31 when individuals already enrolled in a Medicare Advantage plan can switch to another Medicare Advantage plan or return to Original Medicare. They can also enroll in a standalone Part D plan if they switch back to Original Medicare.
4. Part D Late Enrollment Penalty (LEP): A fee added to the Part D premium if a beneficiary goes without creditable prescription drug coverage for 63 or more consecutive days after their Initial Enrollment Period. This penalty continues as long as they have Part D coverage.
5. Creditable Coverage: Prescription drug coverage (through an employer, union, or other source) that is expected to pay, on average, as much as Medicare's standard prescription drug coverage (Part D). Beneficiaries must have creditable coverage to avoid the Part D late enrollment penalty.
6. Medicare Communications and Marketing Guidelines (MCMG): CMS guidelines that govern the activities of Medicare Advantage and Part D plan sponsors, ensuring their marketing efforts are compliant, accurate, and protect beneficiaries from deceptive practices.
7. Dual-Eligible Special Needs Plan (D-SNP): A type of Medicare Advantage plan specifically designed for individuals who are eligible for both Medicare and Medicaid (dual-eligibles). These plans provide coordinated care, combining Medicare and Medicaid services.
8. Chronic Condition Special Needs Plan (C-SNP): A Medicare Advantage plan designed for individuals with specific chronic health conditions (e.g., diabetes, heart disease). These plans provide tailored care to meet the unique needs of people with chronic conditions.
9. Institutional Special Needs Plan (I-SNP): A Medicare Advantage plan designed for individuals who live in nursing homes or require similar levels of care. These plans provide coordinated care for long-term care residents.
10. Medicare Medical Savings Account (MSA): A type of Medicare Advantage plan that combines a high-deductible health plan with a medical savings account. CMS deposits funds into the MSA, which the beneficiary can use for healthcare expenses.
11. Star Ratings: A system used by CMS to evaluate the performance and quality of Medicare Advantage and Part D plans. Plans are rated on a scale of 1 to 5 stars based on factors such as member satisfaction, plan performance, and customer service. A higher star rating indicates better quality.
12. Extra Help (Low-Income Subsidy - LIS): A federal program that helps Medicare beneficiaries with limited income and resources pay for prescription drugs. Extra Help reduces premiums, deductibles, and copayments for Part D coverage.
13. Coordination of Benefits (COB): A process used when a person is covered by more than one health insurance plan. It determines which plan pays first and how much each plan pays for covered services, ensuring the beneficiary receives proper coverage without overpayment.
14. Medigap (Medicare Supplement Insurance): Private insurance policies that help cover some of the costs not paid by Original Medicare, such as copayments, coinsurance, and deductibles. Medigap plans do not work with Medicare Advantage.
15. Involuntary Disenrollment: When a Medicare beneficiary is removed from a Medicare Advantage or Part D plan for reasons such as failing to pay premiums, moving out of the plan’s service area, or losing eligibility.
16. Lock-In Period: A period when Medicare beneficiaries are "locked in" to their Medicare Advantage or Part D plan and cannot make changes except during certain enrollment periods or with a Special Enrollment Period.
17. Plan Finder Tool: A tool provided by CMS on the Medicare.gov website to help beneficiaries compare Medicare Advantage, Part D, and Medigap plans based on cost, coverage, and quality ratings.
18. Advance Beneficiary Notice (ABN): A notice given to Medicare beneficiaries by healthcare providers when a service may not be covered by Medicare. The ABN informs the beneficiary that they may have to pay out-of-pocket if Medicare denies coverage.
19. Plan Service Area: The geographic area where a Medicare Advantage or Part D plan is available. Beneficiaries must live in the service area to be eligible for coverage under the plan.

• Medicare: Primarily for seniors (65+) or those with disabilities. Must have resided in the United States at least 5 years. I must have worked at least 10 years (40 credits).

• Medicaid: Income-based program for low-income individuals, families, children, and certain seniors or disabled persons. Applicants must have legally resided in the USA for at least 5 years, with the exception of pregnant women and children. 

• ACA: Marketplace for purchasing health insurance, with income-based subsidies available to make coverage more affordable.

Life Insurance Eligibility for Most Carriers generally depends on several key factors that insurance companies evaluate before issuing a policy. While each carrier may have specific criteria, the following outlines the most common eligibility factors:

Age:

• Minimum Age: Most carriers require applicants to be at least 18 years old to apply for life insurance.

• Maximum Age: Carriers typically have a maximum age limit, often around 75 to 85 years old for traditional life insurance policies. The availability of certain policy types, such as term life insurance, may be more limited for older applicants.

• Children: The policyowner, typically the parent (or grandparent) must have at least twice of the amount of death benefit as the applicant child.

Health Condition

• Medical Underwriting: Most carriers evaluate your health through a medical underwriting process, which includes:
  • A health questionnaire
  • Medical history review
  • Possibly a medical exam (for fully underwritten policies)
  • Lab tests, such as blood work or a urinalysis

• Guaranteed Issue Policies: For applicants with severe health conditions or those who prefer to skip the medical exam, some carriers offer guaranteed issue life insurance. These policies do not require medical exams but typically have higher premiums and lower death benefits.

Lifestyle:

Smoking/Drug Use: Tobacco use, including cigarettes, cigars, and vaping, affects eligibility and premiums. Applicants who smoke generally face higher premiums. Some carriers also ask about recreational drug use and substance abuse history.

• Occupation and Hobbies: Individuals in dangerous occupations (e.g., construction, aviation, or military) or with risky hobbies (e.g., skydiving, scuba diving, extreme sports) may face higher premiums or be excluded from coverage for those activities.

Citizenship and Residency

• U.S. Citizenship: Most carriers require applicants to be U.S. citizens or permanent legal residents (green card holders).
• Non-U.S. Citizens: Some carriers may offer life insurance to non-citizens, provided they have valid visas and have been residing in the U.S. for an extended period.

Income and Financial Justification:

• Income: Insurance carriers often assess whether the amount of life insurance applied for is reasonable in relation to your income and financial situation. This ensures that the coverage amount is justified and aligns with the applicant's needs.
• Net Worth: High-value policies may require proof of assets, especially for higher death benefit amounts.

Type of Policy:

• Term Life Insurance: Easier to qualify for, especially for younger and healthier individuals. Term life provides coverage for a specific period (e.g., 10, 20, or 30 years) and is typically more affordable.
• Whole Life Insurance: Available for longer coverage, usually until death, with a savings component. Whole life policies may be more restrictive in terms of eligibility, especially as age increases.
• No-Exam Life Insurance: Policies like simplified issue or guaranteed issue life insurance do not require a medical exam but often come with higher premiums and coverage limitations.

Family Medical History

• Many carriers inquire about the applicant's family medical history, particularly concerning genetic conditions such as heart disease, cancer, and diabetes. This information helps assess the risk of early death due to hereditary illnesses.

Financial History

• Bankruptcy: Some carriers may not offer policies if the applicant has recently filed for bankruptcy, as it could raise concerns about the applicant’s ability to maintain premium payments.

Past Insurance Applications

• Insurance carriers often ask if the applicant has been declined or denied life insurance in the past. Multiple denials may negatively impact eligibility with future carriers.