Overview
All health care policies are not created equal. To choose the best plan type for you, you must first understand their differences. Health insurance plans can be broken into two basic categories, the traditional indemnity plan (also called "fee-for service") and the managed-care plan. Premium costs vary depending on the type of plan, location, benefits offered, deductible, and age and sex of the insured. Generally, the indemnity plan is the most expensive followed in decreasing order by PPO plans, POS plans, and HMO plans.
Medicare – for those who have qualified for Social Security – is also important to understand.
Types of health insurance Indemnity
Indemnity plans allow you to choose any doctor or hospital when seeking medical care. These plans typically have a deductible that must be met before any benefits are payable to the insured. After this deductible, the plans pay a co-insurance percentage, typically 70% to 90% of billed charges. The remainder of the bill is paid by the insured. While these plans usually offer full freedom of provider choice, they are typically more expensive. Managed care options limit the choice of service provider in different ways but are generally more economical.
Managed Care – HMO
With the least freedom (in terms of physician and facility selection) and lowest cost, the Health Maintenance Organization (HMO) normally restricts you to a primary care physician who coordinates your care and must refer you to a specialist.
Managed Care – PPO
The Preferred Provider Organization (PPO) gives patients the choice of staying within the network or seeking care outside the group. If you stay within the network, 90-100% of the cost is normally covered while if you go outside the network you submit the claims, similar to a indemnity policy, and typically get 70% of the cost covered.
Managed Care – POS
Less expensive than PPOs, Point-of-Service plans (POS) still provide more freedom than HMOs. For basic care, you can stay within the network but if you choose to see a specialist outside of the HMO you simply pay a percentage of his charges.
Federal: Medicare
Medicare provides coverage for people who have qualified for Social Security (usually 40 quarters of work subject to Social Security). The majority of people who qualify for Medicare become eligible at age 65. Under some circumstances, extreme disabilities may qualify a person for Medicare before age 65. Medicare provides comprehensive coverage, but can have some larger co-insurance payments than many traditional plans. Because of these co-payments, many Medicare recipients buy relatively inexpensive supplements.
Important managed care provisions Access to specialists.
Typically in HMOs, a patient's care is managed by a primary care physician, a family practitioner or internist. This physician, the gatekeeper, provides the majority of care and controls access to specialists, tests, and procedures. Their goal is to keep costs down which may mean limiting specialists and certain tests. Some plans may not even have hepatologists or gastroenterologists familiar with hepatitis within their network. It is essential to select a plan that gives you the expertise you need.
Access to emergency care.
Managed care plans may limit accessibility to emergency rooms. Know what type of restrictions exist before you can go to an emergency room. Do you need approval from the gatekeeper? And, what if you are out of town? Will the managed care plan cover for you to see someone out of the plan's physician network? Do you need approval first? If so, is it usually granted quickly?
Access to treatments, medications, tests.
Pay particular attention to emerging or experimental treatments. There are only a few approved medications to treat hepatitis today, and it's a long process before new medications receive approval. Will your plan allow you to access treatments? Check to see if your plan covers new medications and ask to see the list of the formally covered drugs. Check to specifically see whether medications like interferon are covered, and for what conditions. In addition, what's the lifetime limit (if any) that the plan will pay towards drugs? Important indemnity provisions Your true cost cannot just be judged by the premium alone.
There is also the amount that you are expected to pay – the out-of-pocket-costs. These charges include the deductible (the annual dollar amount you must spend on health care before the insurance company picks up the cost). Normally, the higher the deductible the lower the premium is.
Out-of-pocket costs also include the portion of the bill you're expected to pay after your premium is met – the co-payment. In indemnity plans, the co-payment is usually 20% of the fees. However, the insurance company may limit its payment to 80% of what they feel is the reasonable and customary charge for a service – even if your doctor or hospital charges a larger amount – leaving you to pay the difference. You should also check whether there is an out-of-pocket maximum; you may want that if a serious illness occurs.
Stick with a major medical policy which covers both hospital stays and physician services in and out of the hospital.
There are cheaper plans which offer a fixed rate per day in the hospital or dread-disease policies which pay only if you contract a specific disease like cancer but these policies give you very limited coverage. Does it wear a cap? There are at least three possible types of caps or maximum payable benefits. The first is a lifetime dollar limit for each insured person. Most set that cap at a $1 million, which many experts argue is too low for people with chronic conditions.
There also may be a cap on the allowable benefit for specific illnesses. Or there may be a cap pertaining to a specific time period, such as a year. It's important to inquire about caps of any kind!
Other important details You ought to know how "medical care" and "medically necessary treatment" are specifically defined. If necessary, patients should know how to appeal treatment rejection decisions. You also need to know what provider restrictions exist and how they may affect treatment decisions. For example, does the doctor charge a discounted rate based on volume of patients, or does he receive a certain amount per patient per month or year, known as a "capitation." If the patient's care exceeds this amount, the doctor must cover the expense. This may cause a doctor to limit care.
Good news!
No longer can insurance companies deny you coverage due to a pre-existing condition. The Kassebaum-Kennedy health insurance reform bill prohibits this practice as well as allowing employees to transfer insurance policies between employers. The bill, however, does not stop insurance companies from charging higher premiums for people with previous conditions.
Investigate before you buy
The National Committee for Quality Assurance (NCQA) offers health insurer accreditation based on a rigorous evaluation of clinical quality, member satisfaction, and a comprehensive assessment of key systems and processes.
NCQA also offers an excellent online interactive tool covering hundreds of plans that generates a customized report card for the plans in your area. NCQA is a private nonprofit organization committed to improving the quality of our nation's health care. NCQA sets standards for the quality of care and service that health plans provide to their members. Health plans that meet our standards receive NCQA Accreditation, which is nationally recognized as a seal of approval.
Insurance care problems?
If you do not receive the care you think you deserve, here are
four possible courses of action:
Medicare – for those who have qualified for Social Security – is also important to understand.
Indemnity plans allow you to choose any doctor or hospital when seeking medical care. These plans typically have a deductible that must be met before any benefits are payable to the insured. After this deductible, the plans pay a co-insurance percentage, typically 70% to 90% of billed charges. The remainder of the bill is paid by the insured. While these plans usually offer full freedom of provider choice, they are typically more expensive. Managed care options limit the choice of service provider in different ways but are generally more economical.
Managed Care – HMO
With the least freedom (in terms of physician and facility selection) and lowest cost, the Health Maintenance Organization (HMO) normally restricts you to a primary care physician who coordinates your care and must refer you to a specialist.
Managed Care – PPO
The Preferred Provider Organization (PPO) gives patients the choice of staying within the network or seeking care outside the group. If you stay within the network, 90-100% of the cost is normally covered while if you go outside the network you submit the claims, similar to a indemnity policy, and typically get 70% of the cost covered.
Managed Care – POS
Less expensive than PPOs, Point-of-Service plans (POS) still provide more freedom than HMOs. For basic care, you can stay within the network but if you choose to see a specialist outside of the HMO you simply pay a percentage of his charges.
Federal: Medicare
Medicare provides coverage for people who have qualified for Social Security (usually 40 quarters of work subject to Social Security). The majority of people who qualify for Medicare become eligible at age 65. Under some circumstances, extreme disabilities may qualify a person for Medicare before age 65. Medicare provides comprehensive coverage, but can have some larger co-insurance payments than many traditional plans. Because of these co-payments, many Medicare recipients buy relatively inexpensive supplements.
Typically in HMOs, a patient's care is managed by a primary care physician, a family practitioner or internist. This physician, the gatekeeper, provides the majority of care and controls access to specialists, tests, and procedures. Their goal is to keep costs down which may mean limiting specialists and certain tests. Some plans may not even have hepatologists or gastroenterologists familiar with hepatitis within their network. It is essential to select a plan that gives you the expertise you need.
Access to emergency care.
Managed care plans may limit accessibility to emergency rooms. Know what type of restrictions exist before you can go to an emergency room. Do you need approval from the gatekeeper? And, what if you are out of town? Will the managed care plan cover for you to see someone out of the plan's physician network? Do you need approval first? If so, is it usually granted quickly?
Access to treatments, medications, tests.
Pay particular attention to emerging or experimental treatments. There are only a few approved medications to treat hepatitis today, and it's a long process before new medications receive approval. Will your plan allow you to access treatments? Check to see if your plan covers new medications and ask to see the list of the formally covered drugs. Check to specifically see whether medications like interferon are covered, and for what conditions. In addition, what's the lifetime limit (if any) that the plan will pay towards drugs?
There is also the amount that you are expected to pay – the out-of-pocket-costs. These charges include the deductible (the annual dollar amount you must spend on health care before the insurance company picks up the cost). Normally, the higher the deductible the lower the premium is.
Out-of-pocket costs also include the portion of the bill you're expected to pay after your premium is met – the co-payment. In indemnity plans, the co-payment is usually 20% of the fees. However, the insurance company may limit its payment to 80% of what they feel is the reasonable and customary charge for a service – even if your doctor or hospital charges a larger amount – leaving you to pay the difference. You should also check whether there is an out-of-pocket maximum; you may want that if a serious illness occurs.
Stick with a major medical policy which covers both hospital stays and physician services in and out of the hospital.
There are cheaper plans which offer a fixed rate per day in the hospital or dread-disease policies which pay only if you contract a specific disease like cancer but these policies give you very limited coverage.
There also may be a cap on the allowable benefit for specific illnesses. Or there may be a cap pertaining to a specific time period, such as a year. It's important to inquire about caps of any kind!
NCQA also offers an excellent online interactive tool covering hundreds of plans that generates a customized report card for the plans in your area. NCQA is a private nonprofit organization committed to improving the quality of our nation's health care. NCQA sets standards for the quality of care and service that health plans provide to their members. Health plans that meet our standards receive NCQA Accreditation, which is nationally recognized as a seal of approval.
four possible courses of action:
- Instead of speaking with an insurance clerk, get hold of a vice president or manager. Clerks don't have the authority to make decisions that deviate from their list of rules.
- Get a lawyer involved.
- Call your local newspaper and get a reporter involved.
- If all else fails to work, contact your congressman for assistance.
