This press release came from California’s Insurance Commissioner. Unfortunately, what he had to say about California is true across our country. The press release contains information of value to all since the Foundation for Health Coverage Education is nationwide.
"With 1 in 10 Californians grappling with unemployment and Sacramento’s unemployment rate at 10.4 percent, Insurance Commissioner Steve Poizner today highlighted the Foundation for Health Coverage Education (FHCE) Coverageforall.org Web site, a resource for those who may have lost their health insurance due to the tough economic times.
"The event held at the State Capitol is the second in a series of events Commissioner Poizner is holding to inform the public of their health care options during the recession.
“In the first month of the year, nearly 80,000 Californians lost their jobs and with that, their health insurance,” said Commissioner Poizner. “The census bureau estimates that nearly 1 out of 5 Californians lacked health insurance at one time or another during the last 12 months. There are resources out there, both public and private, that can help people who don’t have health insurance and want to know what their options are. One of those resources is Foundation for Health Coverage Education’s coverageforall.org, where people can go to find out what’s available for them given their particular situation.”
"FHCE operates a U.S. Uninsured Help Line at 800-234-1317 as a resource in addition to the Web site. The Web site and hotline are designed to provide access to hundreds of state and federal programs. The nonprofit organization currently provides access to 175 public healthcare program applications online, allowing Americans seeking government-sponsored health coverage to apply for the programs that best meet their needs.
“A lot of people don’t know these programs exist. What we are doing is making it easier for people in need to access all of their local and statewide options,” said Phil Lebherz, founder of the nonprofit organization.
"FHCE is a non-profit 501 (c) 3 organization with a mission to help simplify public and private health insurance eligibility information. In addition to its U.S. Uninsured Help Line (800) 234-1317 and website www.coverageforall.org, FHCE offers free consumer guides such as the Health Care Options Matrix available for all 50 states."
Wednesday, March 11, 2009
Thursday, February 26, 2009
Health Insurance Shopping Keys
Shopping for health insurance is right up there with doing your income tax.
Gotta be done.
Don’t want to do it.
Afraid of the cost.
Perhaps this list will help take some of the pain out of the process.
When you are shopping for new health insurance, you can separate the good ones from the bad ones with these key items:
Customer Service and Company Strength – How do you find out anyway?? Turns out, it’s pretty easy! There is a national organization that keeps track of this information for you, it’s the National Association of Insurance Commissioners – and yes, they have a web site: http://www.naic.org/consumer_home.htm
On the left side of the NAIC web page, you’ll see: “Consumer Information Source (CIS): File and/or search complaints for individual insurance companies” Click on it. A Complaint Ratio of 1.0 is average. Less than 1.0 is better. More than 1.0 is definitely not better.
Enter your favorite insurance company name, choose your state. Statement Type is “All,” Business Type is “Life/Accident/Health,” and then click: Find Company. Then click on “Closed Complaints,” and “Closed Complaint Ratio Report,” finally, choose “Individual Accident and Health.” Voila! There’s the info. Not just the Complaint Ratio but also their financial position. You're asking yourself: Why didn't I know about this?
The “Network” – All good health insurance companies have provider networks. These are called PPO Networks or Preferred Provider Networks. So, first of all, how big is the network? Did you know that it will cost you a lot more to use a provider that is out of network? Is your doctor in the network? This item alone could be a deal breaker for you. Are the hospitals near you, or are hospitals you care about, in the network? All of this information is available to you BEFORE you make a decision. On the insurance company's web site they will highlight their network and give you the ability to search for providers. Do this! It's important.
Type of Policy - Here’s where it starts getting complicated. There are PPOs and HMOs and Indemnity policies… what works best for you is a very personal decision. However, the policies with more coverage cost more. You knew that. Here’s what people don’t seem to want to do, though: They don’t sit down and think about how they use the healthcare system. Do you go to the doctor frequently? Did you know that having a $30 copay for doctor visits could increase the cost of your insurance by $100 or more a month? If you go to the doctor twice a year do you want to add $1,200 to your annual cost for a $30 copay? Are your children young requiring frequent medical attention? Are you older when “things start to break?”
On the AIG web site, you’ll see “Consumers, Insure U.” Click on it. They have done an excellent job of highlighting what to consider based on your age and personal situation. Spend a few minutes here and save big bucks in the long run.
Competitive Pricing – don’t make the mistake of making this number one on your search criteria. Notice that I put it last. And yes, an experienced broker can help you sort through this after you’ve done a little work to learn what to ask. Remember there is a difference between an “agent” and a “broker.” A broker represents many insurance companies. An agent only one.
All insurance companies use the same set of statistics to figure out how to price their product. So, if a policy from one company is dramatically less than a “similar policy” from another company, there’s probably a reason and it's not because the insurance company is trying to be nice.
Can I help? Sure, give me a call or best of luck to you!
Gotta be done.
Don’t want to do it.
Afraid of the cost.
Perhaps this list will help take some of the pain out of the process.
When you are shopping for new health insurance, you can separate the good ones from the bad ones with these key items:
- Customer Service and Company Strength
- The Network
- The Type of Policy
- Price
Customer Service and Company Strength – How do you find out anyway?? Turns out, it’s pretty easy! There is a national organization that keeps track of this information for you, it’s the National Association of Insurance Commissioners – and yes, they have a web site: http://www.naic.org/consumer_home.htm
On the left side of the NAIC web page, you’ll see: “Consumer Information Source (CIS): File and/or search complaints for individual insurance companies” Click on it. A Complaint Ratio of 1.0 is average. Less than 1.0 is better. More than 1.0 is definitely not better.
Enter your favorite insurance company name, choose your state. Statement Type is “All,” Business Type is “Life/Accident/Health,” and then click: Find Company. Then click on “Closed Complaints,” and “Closed Complaint Ratio Report,” finally, choose “Individual Accident and Health.” Voila! There’s the info. Not just the Complaint Ratio but also their financial position. You're asking yourself: Why didn't I know about this?
The “Network” – All good health insurance companies have provider networks. These are called PPO Networks or Preferred Provider Networks. So, first of all, how big is the network? Did you know that it will cost you a lot more to use a provider that is out of network? Is your doctor in the network? This item alone could be a deal breaker for you. Are the hospitals near you, or are hospitals you care about, in the network? All of this information is available to you BEFORE you make a decision. On the insurance company's web site they will highlight their network and give you the ability to search for providers. Do this! It's important.
Type of Policy - Here’s where it starts getting complicated. There are PPOs and HMOs and Indemnity policies… what works best for you is a very personal decision. However, the policies with more coverage cost more. You knew that. Here’s what people don’t seem to want to do, though: They don’t sit down and think about how they use the healthcare system. Do you go to the doctor frequently? Did you know that having a $30 copay for doctor visits could increase the cost of your insurance by $100 or more a month? If you go to the doctor twice a year do you want to add $1,200 to your annual cost for a $30 copay? Are your children young requiring frequent medical attention? Are you older when “things start to break?”
On the AIG web site, you’ll see “Consumers, Insure U.” Click on it. They have done an excellent job of highlighting what to consider based on your age and personal situation. Spend a few minutes here and save big bucks in the long run.
Competitive Pricing – don’t make the mistake of making this number one on your search criteria. Notice that I put it last. And yes, an experienced broker can help you sort through this after you’ve done a little work to learn what to ask. Remember there is a difference between an “agent” and a “broker.” A broker represents many insurance companies. An agent only one.
All insurance companies use the same set of statistics to figure out how to price their product. So, if a policy from one company is dramatically less than a “similar policy” from another company, there’s probably a reason and it's not because the insurance company is trying to be nice.
Can I help? Sure, give me a call or best of luck to you!
Tuesday, January 27, 2009
When COBRA strikes: How to maintain affordable health insurance
For those joining the ranks of the unemployed, the prospects for health care coverage can be frightening.
Enacted in 1986, COBRA's high cost is a contributing reason why 47 million Americans are uninsured — a figure in a report from Families USA.
"There are some misconceptions about COBRA," said Ellen Laden, spokesperson for United Healthcare Golden Rule Insurance, one of the two largest health insurers in the country that offers medical plans for unemployed. "If you never had to use it, you don't know. In today's economy, more and more people are finding themselves losing jobs or losing benefits or are covered by health insurance, but their families no longer are."
To be eligible for COBRA coverage, an employee must have been working for a company of 20 or more. Employees laid off from smaller businesses are not eligible. Also ineligible are those who have worked for companies that have dropped medical coverage or have closed suddenly.
"One of the problems with COBRA is it tends to be expensive," said Laden from her office in Indianapolis. "It costs up to 102 percent of the cost of health insurance (for family coverage)."
COBRA premiums vary from state to state, and Laden said cost can be computed at three or four times what a worker had been paying each month for the medical coverage at that job. That means if you had been paying $100/month, depending upon your employers benefit program, your COBRA could be as much as $300 or $400/month.
Employers often pay 75 percent of health insurance costs, and large employers pay even more. Many who leave a company and its coverage are not ready for the sticker shock once they have to pay for their own coverage.
So, consumers should shop around with a broker (you can call me for help at 888-943-3336), before resorting to the popular course of action with COBRA.
But there is one time when COBRA becomes the preferred alternative, said Laden: people who lose employer coverage and have serious pre-existing conditions or chronic illnesses.
"That prevents them from getting coverage in the ordinary market. It is important for those people to continue coverage under COBRA for as long as they can," said Laden.
Once COBRA coverage is exhausted, insurees become eligible for HIPAA — Health Insurance Portability and Accountability Act. Enacted in 1996, it guarantees coverage for that 10 percent of the population who cannot get affordable alternatives in the individual market after COBRA.
Many policyholders can mix and match coverage, taking COBRA for themselves if they have an ongoing medical condition but picking up less involved coverage for their family members. The main thing is that different people have different needs for coverage and for their budget, and those two things must be considered when deciding on a policy.
"There's no one right plan for everybody. Every family has unique needs. You need to be a good consumer. The most important thing is no one should be without health insurance coverage," said Laden. "Options are available for health care and budget needs. It's tempting, when the budget is squeezed and there's no revenue, to let health insurance go. But you can get an injury that is serious and needs hospitalization, and that cost can put you into bankruptcy. You may never be able to pay it off."
Once again - if you find yourself in these circumstances, give me a call at 888-943-3336.
Enacted in 1986, COBRA's high cost is a contributing reason why 47 million Americans are uninsured — a figure in a report from Families USA.
"There are some misconceptions about COBRA," said Ellen Laden, spokesperson for United Healthcare Golden Rule Insurance, one of the two largest health insurers in the country that offers medical plans for unemployed. "If you never had to use it, you don't know. In today's economy, more and more people are finding themselves losing jobs or losing benefits or are covered by health insurance, but their families no longer are."
To be eligible for COBRA coverage, an employee must have been working for a company of 20 or more. Employees laid off from smaller businesses are not eligible. Also ineligible are those who have worked for companies that have dropped medical coverage or have closed suddenly.
"One of the problems with COBRA is it tends to be expensive," said Laden from her office in Indianapolis. "It costs up to 102 percent of the cost of health insurance (for family coverage)."
COBRA premiums vary from state to state, and Laden said cost can be computed at three or four times what a worker had been paying each month for the medical coverage at that job. That means if you had been paying $100/month, depending upon your employers benefit program, your COBRA could be as much as $300 or $400/month.
Employers often pay 75 percent of health insurance costs, and large employers pay even more. Many who leave a company and its coverage are not ready for the sticker shock once they have to pay for their own coverage.
So, consumers should shop around with a broker (you can call me for help at 888-943-3336), before resorting to the popular course of action with COBRA.
But there is one time when COBRA becomes the preferred alternative, said Laden: people who lose employer coverage and have serious pre-existing conditions or chronic illnesses.
"That prevents them from getting coverage in the ordinary market. It is important for those people to continue coverage under COBRA for as long as they can," said Laden.
Once COBRA coverage is exhausted, insurees become eligible for HIPAA — Health Insurance Portability and Accountability Act. Enacted in 1996, it guarantees coverage for that 10 percent of the population who cannot get affordable alternatives in the individual market after COBRA.
Many policyholders can mix and match coverage, taking COBRA for themselves if they have an ongoing medical condition but picking up less involved coverage for their family members. The main thing is that different people have different needs for coverage and for their budget, and those two things must be considered when deciding on a policy.
"There's no one right plan for everybody. Every family has unique needs. You need to be a good consumer. The most important thing is no one should be without health insurance coverage," said Laden. "Options are available for health care and budget needs. It's tempting, when the budget is squeezed and there's no revenue, to let health insurance go. But you can get an injury that is serious and needs hospitalization, and that cost can put you into bankruptcy. You may never be able to pay it off."
Once again - if you find yourself in these circumstances, give me a call at 888-943-3336.
Tuesday, January 6, 2009
Generic Drugs vs. Brand Name Drugs... Who Cares?
First of all, why should you care? Because you can save a boatload of money, that's why!
This is where the big bucks are. If you take one pill a day and the brand name drug is $3 a pill (yes, that's realistic). In one year, you'll spend $1,095 for that one medication. A generic drug purchased at Wal Mart with no health insurance will cost you $4 for 30 days - that's $48.00 a year - a $1,046 savings.
What's the bottom line? Here's some comments from a recent study: "...the research reconfirms that FDA-approved generics provide the same medicine with the same clinical effects at a substantial cost savings." The results of 30 studies done since 1984 comparing nine sub-classes of cardiovascular drugs to generic counterparts were combined and showed that brand-name drugs did not offer any advantage for patients' clinical outcomes (Journal of the American Medical Association).
So! Take the kids out on the town or the family out to dinner once a month and use generic drugs whenever possible.
This is where the big bucks are. If you take one pill a day and the brand name drug is $3 a pill (yes, that's realistic). In one year, you'll spend $1,095 for that one medication. A generic drug purchased at Wal Mart with no health insurance will cost you $4 for 30 days - that's $48.00 a year - a $1,046 savings.
What's the bottom line? Here's some comments from a recent study: "...the research reconfirms that FDA-approved generics provide the same medicine with the same clinical effects at a substantial cost savings." The results of 30 studies done since 1984 comparing nine sub-classes of cardiovascular drugs to generic counterparts were combined and showed that brand-name drugs did not offer any advantage for patients' clinical outcomes (Journal of the American Medical Association).
So! Take the kids out on the town or the family out to dinner once a month and use generic drugs whenever possible.
Wednesday, December 17, 2008
Losing your job and health insurance
What could be worse? Not only is it the holidays, but you just got laid off – and along comes a letter informing you that your COBRA will only be $1,400 a month…
OK, maybe $1,400 is high for you, but it certainly isn’t high for many of the folks who have this little problem. So, what are your options? No, running away to Canada will not solve the problem – besides, your family is here and it’s the holidays, remember?
Seriously, let’s take a look at what options you have. First of all, not having insurance is not a good option and here’s why: If you or any family member has an accident (and that’s what’s most likely), you could easily see a bill for $75,000.
That’s what a client recently told me it cost her for her daughter’s broken leg. And if you have assets – any assets, the doctors and the hospital will get paid one way or another. So, at the very least, get some accident insurance. It’s cheap and if you are healthy, accidents are your biggest concern. This may not be the best solution however…
What if you have some pre-existing conditions? If you or any family member has pre-existing conditions, treat this decision regarding health insurance very, very carefully and here’s why: With certain pre-existing conditions, a person may be ineligible for standard health insurance. Now, don’t panic; there are options here. First of all, examine the health of your family. Are you the person who lost the job with the benefits? And are you the person with the serious pre-existing conditions? If so, get two policies. One for you (COBRA), and one for the rest of your family.
For you, be careful. Understand what your rights are under the HIPAA regulations (I know, what’s HIPAA?). I’m not going to take the time to explain it here – it’s complicated. Go to http://www.hmohelp.ca.gov/dmhc_consumer/hp/hp_hipaacp.aspx for information.
Here’s the bad news: You must first use up all your Federal COBRA/ Cal-COBRA if you qualify for it. Costly? Perhaps. Be careful. The risk is that you (or a family member) may lose the ability to obtain health insurance in the future. So, as I said, be careful here. If it’s a family member with the pre-existing condition, the problem gets more complicated. Get some expert advice.
For members of the family that are healthy, you have all kinds of options. Find the most cost effective plan that you can afford for them. It may be the COBRA offering - don't discard it without comparing it to other plans. Understand, however, you must get coverage in place in less than 62 days after your work-sponsored health insurance ends. Otherwise, you lose the benefit of continuous coverage and that means that if it is determined that there is a pre-existing condition, it is not going to be covered for as long as 12 months! That could be a big deal.
Yup, time's a'wastin' and it’s the little things that will get you into hot water in these circumstances. Give me a call. If I can help in any way, I will.
OK, maybe $1,400 is high for you, but it certainly isn’t high for many of the folks who have this little problem. So, what are your options? No, running away to Canada will not solve the problem – besides, your family is here and it’s the holidays, remember?
Seriously, let’s take a look at what options you have. First of all, not having insurance is not a good option and here’s why: If you or any family member has an accident (and that’s what’s most likely), you could easily see a bill for $75,000.
That’s what a client recently told me it cost her for her daughter’s broken leg. And if you have assets – any assets, the doctors and the hospital will get paid one way or another. So, at the very least, get some accident insurance. It’s cheap and if you are healthy, accidents are your biggest concern. This may not be the best solution however…
What if you have some pre-existing conditions? If you or any family member has pre-existing conditions, treat this decision regarding health insurance very, very carefully and here’s why: With certain pre-existing conditions, a person may be ineligible for standard health insurance. Now, don’t panic; there are options here. First of all, examine the health of your family. Are you the person who lost the job with the benefits? And are you the person with the serious pre-existing conditions? If so, get two policies. One for you (COBRA), and one for the rest of your family.
For you, be careful. Understand what your rights are under the HIPAA regulations (I know, what’s HIPAA?). I’m not going to take the time to explain it here – it’s complicated. Go to http://www.hmohelp.ca.gov/dmhc_consumer/hp/hp_hipaacp.aspx for information.
Here’s the bad news: You must first use up all your Federal COBRA/ Cal-COBRA if you qualify for it. Costly? Perhaps. Be careful. The risk is that you (or a family member) may lose the ability to obtain health insurance in the future. So, as I said, be careful here. If it’s a family member with the pre-existing condition, the problem gets more complicated. Get some expert advice.
For members of the family that are healthy, you have all kinds of options. Find the most cost effective plan that you can afford for them. It may be the COBRA offering - don't discard it without comparing it to other plans. Understand, however, you must get coverage in place in less than 62 days after your work-sponsored health insurance ends. Otherwise, you lose the benefit of continuous coverage and that means that if it is determined that there is a pre-existing condition, it is not going to be covered for as long as 12 months! That could be a big deal.
Yup, time's a'wastin' and it’s the little things that will get you into hot water in these circumstances. Give me a call. If I can help in any way, I will.
Tuesday, December 9, 2008
Check Out Online Health Care Ratings
People still rely on the opinions of friends and family for suggestions on health care providers. And personal experience remains an unmatched resource. But what if you could check that information against a professional rating? Would it interest you to know that there are healthcare rating services available to you at no cost?
These ratings organizations analyze data that health care providers are required to submit to regulatory agencies, such as the Centers for Medicare & Medicaid Services, to formulate rankings. Demands for quality health care information have driven the government and providers to come up with measures and make them publicly available. Health care buyers, including employers, insurance companies and uninsured patients, are beginning to use these ratings to get the best value for their money.
While it’s not perfect, the quality ratings are starting to set up competition between doctors and hospitals. Patients will use the quality ratings more as doctors and other providers refer to them when making health-care recommendations.
If you use these services, be aware that it can be unclear how information is being analyzed to set doctors' ratings for instance. Some doctors may perform more procedures than others. Others might treat sicker patients, who require more extensive and costlier care. An accurate comparison of doctors needs to consider those items. The sites nevertheless provide valuable information when you are considering a medical procedure, or are new to an area.
Always recognize that the best health care occurs when patients and doctors communicate effectively.
Here are a few sites that may be of value to you:
www.Healthgrades.com - Most information is at no charge
www.vitals.com - Ratings on doctors, no charge; Vitals.com allows patients to review and rate their physicians… keep the source in mind!
www.doctorscorecard.com - Also no charge, but this looks like a popularity chart…
www.drscore.com - This site states: They believe that patients are to be trusted and are a good, if not the best, source of information on the quality of medical care. So again, remember the source.
www.consumersresearchcncl.org - Provides consumers' information guides for professional services throughout America. Lots of info here.
www.checkbook.org - A for fee service... Consumers’ CHECKBOOK/The Center for the Study of Services is an independent, nonprofit consumer organization founded in 1974. They are supported entirely by subscription payments and donations from individual consumers.
These ratings organizations analyze data that health care providers are required to submit to regulatory agencies, such as the Centers for Medicare & Medicaid Services, to formulate rankings. Demands for quality health care information have driven the government and providers to come up with measures and make them publicly available. Health care buyers, including employers, insurance companies and uninsured patients, are beginning to use these ratings to get the best value for their money.
While it’s not perfect, the quality ratings are starting to set up competition between doctors and hospitals. Patients will use the quality ratings more as doctors and other providers refer to them when making health-care recommendations.
If you use these services, be aware that it can be unclear how information is being analyzed to set doctors' ratings for instance. Some doctors may perform more procedures than others. Others might treat sicker patients, who require more extensive and costlier care. An accurate comparison of doctors needs to consider those items. The sites nevertheless provide valuable information when you are considering a medical procedure, or are new to an area.
Always recognize that the best health care occurs when patients and doctors communicate effectively.
Here are a few sites that may be of value to you:
www.Healthgrades.com - Most information is at no charge
www.vitals.com - Ratings on doctors, no charge; Vitals.com allows patients to review and rate their physicians… keep the source in mind!
www.doctorscorecard.com - Also no charge, but this looks like a popularity chart…
www.drscore.com - This site states: They believe that patients are to be trusted and are a good, if not the best, source of information on the quality of medical care. So again, remember the source.
www.consumersresearchcncl.org - Provides consumers' information guides for professional services throughout America. Lots of info here.
www.checkbook.org - A for fee service... Consumers’ CHECKBOOK/The Center for the Study of Services is an independent, nonprofit consumer organization founded in 1974. They are supported entirely by subscription payments and donations from individual consumers.
Monday, December 8, 2008
Pointers on Individual Health Insurance
How does individual health insurance differ from group insurance?
Individual health insurance is coverage that a person buys personally compared to Group Health Insurance through an employer. It can be sold to an individual, to a parent and dependent children, or to a family.
The majority of Americans get their health insurance coverage through an employer or through a government program. A growing share of the population purchases private health coverage on an individual basis. Each state independently regulates the type of coverage and how individual policies may be sold.
Where can I buy individual health insurance coverage?
In almost every state, individual health insurance coverage can be purchased through licensed health insurance sales reps known as agents or brokers. Independent agents and brokers sell insurance plans from many companies, and they can help you find the coverage that best suits your individual needs.
You should know that the insurance companies pay agents and brokers a commission for their work. As a result, their services are available to you at no cost. Agents and brokers also provide service on the policies they have sold. They can also help you process claims or with anything else you need regarding your policy.
Brokers are often a better resource than the insurance company’s agent because broker’s have access to many different insurance plans. They are likely to help you find the right plan from the right company for your needs. An agent only has access to their company’s plans.
A key point is that individual health insurance is both costly and complex. You no longer have the benefits of a trained Human Resources organization. A broker can often help you understand how to meet your needs most cost effectively.
Another key point is that on line insurance services price their insurance at "preferred rates." As a buyer, you may then be surprised to find that the actual cost you pay after the insurance company has reviewed your medical background can be significantly higher.
How is individual insurance different from group insurance?
Individual health insurance is very different from the group health insurance you got through an employer. Benefits are generally less extensive than what most people would receive through coverage they have through work.
Cost is usually the key factor for individual health insurance consumers. Deductibles, co-insurance and cost-sharing are also generally higher. Keep in mind, an employer views the benefit program they offer as an incentive used to promote long term employee loyalty. They are willing to pay quite a bit to retain key employees. When you purchase insurance independently, you will see the true cost.
Applicants for individual insurance will need to complete a brief medical questionnaire when applying for benefits. Unlike a group insurance policy, in most states a company can decide not to cover people with very serious medical conditions such as diabetes, HIV or cancer. There are alternatives available for persons with significant pre-existing conditions. These are “guaranteed issue” plans.
How are premium rates determined?
When determining rates, insurance companies use the medical information you provide on their applications. Additionally, they may require information from an applicant's physician or contact the applicant directly. It is sad but true that the doctor’s notes can often be a determining factor.
If the insurance company cannot accurately determine the risk, it will underwrite more conservatively. As an example: A person has a history of high cholesterol but is not taking medication. The circumstances may be that the individual is actually being monitored by the doctor as a means to determine the correct course of treatment. Regardless, the insurance company will likely determine that the cholesterol problem is not controlled and that may result in a decline.
Once the company has determined your health status, you will be assigned a rate class by the company. This will put you into a pool of other insured individuals with similar health status. Your premium will be the rate charged to that entire class of customers. Subsequent annual renewal premium rates will be determined not by your individual claims, but instead by the claims experience of the entire rating class pool.
While all of this may seem negative, the reality is that most people are generally healthy and there are few issues with approval. Furthermore, you can choose more carefully if you are aware of your circumstances. Most important: ask lots of questions when you are applying for insurance.
How are pre-existing medical conditions covered?
In almost every state an insurance company can choose not to offer coverage to people with serious medical conditions. Some individuals decide to not purchase health insurance coverage until they have a known serious medical problem.
Insurance companies look back at pre-existing conditions and may choose not to cover certain conditions for a specified period of time. This is a pre-existing condition, waiting period. The amount of time an insurance company can look back at your medical history, and the length of time this period can last, vary on a state-by-state basis.
In some states, you can receive credit against a pre-existing condition waiting period if you have had prior health insurance coverage within a specified number of days. The amount of the credit against the waiting period is generally proportional to the length of the prior coverage.
Can I still buy individual insurance if I have a very serious pre-existing medical condition?
In most states you can be turned down for individual coverage if you have a very serious medical condition for example diabetes, HIV or cancer.
Fortunately, most states have developed some way to provide uninsurable people with access to individual health insurance coverage. Many states provide coverage to medically uninsurable people through high-risk pools. Some states use other means of providing uninsurable people with access to individual coverage. They may require that all individual health insurance companies issue individual policies regardless of health status, or offer coverage through a designated health insurance company of last resort, etc. A few states still have no means of providing individual health insurance access to people with catastrophic medical conditions. To find out what your state's options are for medically uninsurable individuals, check out the state department of insurance web site.
Keep in mind, there are Guaranteed Issue plans that will accept almost any medical condition. There rates are a little higher, their coverage is not going to be comprehensive, but some insurance is always better than none.
Individual health insurance is coverage that a person buys personally compared to Group Health Insurance through an employer. It can be sold to an individual, to a parent and dependent children, or to a family.
The majority of Americans get their health insurance coverage through an employer or through a government program. A growing share of the population purchases private health coverage on an individual basis. Each state independently regulates the type of coverage and how individual policies may be sold.
Where can I buy individual health insurance coverage?
In almost every state, individual health insurance coverage can be purchased through licensed health insurance sales reps known as agents or brokers. Independent agents and brokers sell insurance plans from many companies, and they can help you find the coverage that best suits your individual needs.
You should know that the insurance companies pay agents and brokers a commission for their work. As a result, their services are available to you at no cost. Agents and brokers also provide service on the policies they have sold. They can also help you process claims or with anything else you need regarding your policy.
Brokers are often a better resource than the insurance company’s agent because broker’s have access to many different insurance plans. They are likely to help you find the right plan from the right company for your needs. An agent only has access to their company’s plans.
A key point is that individual health insurance is both costly and complex. You no longer have the benefits of a trained Human Resources organization. A broker can often help you understand how to meet your needs most cost effectively.
Another key point is that on line insurance services price their insurance at "preferred rates." As a buyer, you may then be surprised to find that the actual cost you pay after the insurance company has reviewed your medical background can be significantly higher.
How is individual insurance different from group insurance?
Individual health insurance is very different from the group health insurance you got through an employer. Benefits are generally less extensive than what most people would receive through coverage they have through work.
Cost is usually the key factor for individual health insurance consumers. Deductibles, co-insurance and cost-sharing are also generally higher. Keep in mind, an employer views the benefit program they offer as an incentive used to promote long term employee loyalty. They are willing to pay quite a bit to retain key employees. When you purchase insurance independently, you will see the true cost.
Applicants for individual insurance will need to complete a brief medical questionnaire when applying for benefits. Unlike a group insurance policy, in most states a company can decide not to cover people with very serious medical conditions such as diabetes, HIV or cancer. There are alternatives available for persons with significant pre-existing conditions. These are “guaranteed issue” plans.
How are premium rates determined?
When determining rates, insurance companies use the medical information you provide on their applications. Additionally, they may require information from an applicant's physician or contact the applicant directly. It is sad but true that the doctor’s notes can often be a determining factor.
If the insurance company cannot accurately determine the risk, it will underwrite more conservatively. As an example: A person has a history of high cholesterol but is not taking medication. The circumstances may be that the individual is actually being monitored by the doctor as a means to determine the correct course of treatment. Regardless, the insurance company will likely determine that the cholesterol problem is not controlled and that may result in a decline.
Once the company has determined your health status, you will be assigned a rate class by the company. This will put you into a pool of other insured individuals with similar health status. Your premium will be the rate charged to that entire class of customers. Subsequent annual renewal premium rates will be determined not by your individual claims, but instead by the claims experience of the entire rating class pool.
While all of this may seem negative, the reality is that most people are generally healthy and there are few issues with approval. Furthermore, you can choose more carefully if you are aware of your circumstances. Most important: ask lots of questions when you are applying for insurance.
How are pre-existing medical conditions covered?
In almost every state an insurance company can choose not to offer coverage to people with serious medical conditions. Some individuals decide to not purchase health insurance coverage until they have a known serious medical problem.
Insurance companies look back at pre-existing conditions and may choose not to cover certain conditions for a specified period of time. This is a pre-existing condition, waiting period. The amount of time an insurance company can look back at your medical history, and the length of time this period can last, vary on a state-by-state basis.
In some states, you can receive credit against a pre-existing condition waiting period if you have had prior health insurance coverage within a specified number of days. The amount of the credit against the waiting period is generally proportional to the length of the prior coverage.
Can I still buy individual insurance if I have a very serious pre-existing medical condition?
In most states you can be turned down for individual coverage if you have a very serious medical condition for example diabetes, HIV or cancer.
Fortunately, most states have developed some way to provide uninsurable people with access to individual health insurance coverage. Many states provide coverage to medically uninsurable people through high-risk pools. Some states use other means of providing uninsurable people with access to individual coverage. They may require that all individual health insurance companies issue individual policies regardless of health status, or offer coverage through a designated health insurance company of last resort, etc. A few states still have no means of providing individual health insurance access to people with catastrophic medical conditions. To find out what your state's options are for medically uninsurable individuals, check out the state department of insurance web site.
Keep in mind, there are Guaranteed Issue plans that will accept almost any medical condition. There rates are a little higher, their coverage is not going to be comprehensive, but some insurance is always better than none.
Monday, December 1, 2008
Health Insurance Glossary
Terms and phrases used by people in the insurance industry.
A
Actuary: A mathematician working for a health insurance company responsible for determining what premiums the company needs to charge based in large part on claims paid verses amounts of premium generated. Their job is to make sure a block of business is priced to be profitable.
Admitting Privileges: The right granted to a doctor to admit patients to a particular hospital.
Agent: Licensed salespersons who represent one or more health insurance companies and presents their products to consumers.
Association: A group. Often, associations can offer individual health insurance plans specially designed for their members.
B
Benefit: Amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss.
Brand-name drug: Prescription drugs marketed with a specific brand name by the company that manufactures it, usually the company which develops and patents it. When patents run out, generic versions of many popular drugs are marketed at lower cost by other companies. Check your insurance plan to see if coverage differs between name-brand and their generic twins.
Broker: Licensed insurance salesperson who obtains quotes and plan from multiple sources information for clients.
C
Carrier: The insurance company or HMO offering a health plan.
Case Management: Case management is a system embraced by employers and insurance companies to ensure that individuals receive appropriate, reasonable health care services.
Certificate of Insurance: The printed description of the benefits and coverage provisions forming the contract between the carrier and the customer. Discloses what it covered, what is not, and dollar limits.
Claim: A request by an individual (or his or her provider) to an individual's insurance company for the insurance company to pay for services obtained from a health care professional.
Co-Insurance: Co-insurance refers to money that an individual is required to pay for services, after a deductible has been paid. In some health care plans, co-insurance is called "co-payment." Co-insurance is often specified by a percentage. For example, the employee pays 20 percent toward the charges for a service and the employer or insurance company pays 80 percent.
Related terms: Co-Payment, Deductible
Co-Payment: Co-payment is a predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers. For example, some HMOs require a $10 "co-payment" for each office visit, regardless of the type or level of services provided during the visit. Co-payments are not usually specified by percentages.
Related terms: Co-Insurance, Deductible
COBRA: Federal legislation that lets you, if you work for an insured employer group of 20 or more employees, continue to purchase health insurance for up to 18 months if you lose your job or your coverage is otherwise terminated. For more information, visit the Department of Labor.
Credit for Prior Coverage: This is something that may or may not apply when you switch employers or insurance plans. A pre-existing condition waiting period met under while you were under an employer's (qualifying) coverage can be honored by your new plan, if any interruption in the coverage between the two plans meets state guidelines.
D
Deductible: The amount an individual must pay for health care expenses before insurance (or a self-insured company) covers the costs. Often, insurance plans are based on yearly deductible amounts.
Related terms: Co-Insurance, Co-Payment
Denial Of Claim: Refusal by an insurance company to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional.
Dependents: Spouse and/or unmarried children (whether natural, adopted or step) of an insured.
E
Effective Date: The date your insurance is to actually begin. You are not covered until the policies effective date.
Exclusions: Medical services that are not covered by an individual's insurance policy.
Explanation of Benefits: The insurance company's written explanation to a claim, showing what they paid and what the client must pay. Sometimes accompanied by a benefits check.
G
Generic Drug: A "twin" to a "brand name drug" once the brand name company's patent has run out and other drug companies are allowed to sell a duplicate of the original. Generic drugs are cheaper, and most prescription and health plans reward clients for choosing generics.
Group Insurance: Coverage through an employer or other entity that covers all individuals in the group.
H
Health Maintenance Organizations (HMOs): Health Maintenance Organizations represent "pre-paid" or "capitated" insurance plans in which individuals or their employers pay a fixed monthly fee for services, instead of a separate charge for each visit or service. The monthly fees remain the same, regardless of types or levels of services provided, Services are provided by physicians who are employed by, or under contract with, the HMO. HMOs vary in design. Depending on the type of the HMO, services may be provided in a central facility, or in a physician's own office (as with IPAs.)
HIPAA: A Federal law passed in 1996 that allows persons to qualify immediately for comparable health insurance coverage when they change their employment or relationships. It also creates the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care. Full name is "The Health Insurance
Portability and Accountability Act of 1996."
I
In-network: Providers or health care facilities which are part of a health plan's network of providers with which it has negoiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts.
Indemnity Health Plan: Indemnity health insurance plans are also called "fee-for-service." These are the types of plans that primarily existed before the rise of HMOs, IPAs, and PPOs. With indemnity plans, the individual pays a pre-determined percentage of the cost of health care services, and the insurance company (or self-insured employer) pays the other percentage. For example, an individual might pay 20 percent for services and the insurance company pays 80 percent. The fees for services are defined by the providers and vary from physician to physician. Indemnity health plans offer individuals the freedom to choose their health care professionals.
Independent Practice Associations: IPAs are similar to HMOs, except that individuals receive care in a physician's own office, rather than in an HMO facility.
Individual Health Insurance: Health insurance coverage on an individual, not group, basis. The premium is usually higher for an individual health insurance plan than for a group policy, but you may not qualify for a group plan.
L
Lifetime Maximum Benefit (or Maximum Lifetime Benefit): the maximum amount a health plan will pay in benefits to an insured individual during that individual's lifetime.
Limitations: a limit on the amount of benefits paid out for a particular covered expense, as disclosed on the Certificate of Insurance.
Long-Term Care Policy: Insurance policies that cover specified services for a specified period of time. Long-term care policies (and their prices) vary significantly. Covered services often include nursing care, home health care services, and custodial care.
Long-term Disability Insurance: Pays an insured a percentage of their monthly earnings if they become disabled.
LOS: LOS refers to the length of stay. It is a term used by insurance companies, case managers and/or employers to describe the amount of time an individual stays in a hospital or in-patient facility.
M
Managed Care: A medical delivery system that attempts to manage the quality and cost of medical services that individuals receive. Most managed care systems offer HMOs and PPOs that individuals are encouraged to use for their health care services. Some managed care plans attempt to improve health quality, by emphasizing prevention of disease.
Maximum Dollar Limit: The maximum amount of money that an insurance company (or self-insured company) will pay for claims within a specific time period. Maximum dollar limits vary greatly. They may be based on or specified in terms of types of illnesses or types of services. Sometimes they are specified in terms of lifetime, sometimes for a year.
N
Network: A group of doctors, hospitals and other health care providers contracted to provide services to insurance
companies customers for less than their usual fees. Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less for using a network provider.
O
Open-ended HMOs: HMOs which allow enrolled individuals to use out-of-plan providers and still receive partial or full coverage and payment for the professional's services under a traditional indemnity plan.
Out-of-Plan (Out-of-Network): This phrase usually refers to physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan (usually an HMO or PPO). Depending on an individual's health insurance plan, expenses incurred by services provided by out-of-plan health professionals may not be covered, or covered only in part by an individual's insurance company.
Out-Of-Pocket Maximum: A predetermined limited amount of money that an individual must pay out of their own savings, before an insurance company or (self-insured employer) will pay 100 percent for an individual's health care expenses.
Outpatient: An individual (patient) who receives health care services (such as surgery) on an outpatient basis, meaning they do not stay overnight in a hospital or inpatient facility. Many insurance companies have identified a list of tests and procedures (including surgery) that will not be covered (paid for) unless they are performed on an outpatient basis. The term outpatient is also used synonymously with ambulatory to describe health care facilities where procedures are performed.
P
Pre-Admission Certification: Also called pre-certification review, or pre-admission review. Approval by a case manager or insurance company representative (usually a nurse) for a person to be admitted to a hospital or in-patient facility, granted prior to the admittance. Pre-admission certification often must be obtained by the individual. Sometimes, however, physicians will contact the appropriate individual. The goal of pre-admission certification is to ensure that individuals are not exposed to inappropriate health care services (services that are medically unnecessary).
Pre-Admission Review: A review of an individual's health care status or condition, prior to an individual being admitted to an inpatient health care facility, such as a hospital. Pre-admission reviews are often conducted by case managers or insurance company representatives (usually nurses) in cooperation with the individual, his or her physician or health care provider, and hospitals.
Pre-existing Conditions: A medical condition that is excluded from coverage by an insurance company, because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company.
Preadmission Testing: Medical tests that are completed for an individual prior to being admitted to a hospital or inpatient health care facility.
Preferred Provider Organizations (PPOs): You or your employer receive discounted rates if you use doctors from a pre-selected group. If you use a physician outside the PPO plan, you must pay more for the medical care.
Primary Care Provider (PCP): A health care professional (usually a physician) who is responsible for monitoring an individual's overall health care needs. Typically, a PCP serves as a "quarterback" for an individual's medical care, referring the individual to more specialized physicians for specialist care.
Provider: Provider is a term used for health professionals who provide health care services. Sometimes, the term refers only to physicians. Often, however, the term also refers to other health care professionals such as hospitals, nurse practitioners, chiropractors, physical therapists, and others offering specialized health care services.
R
Reasonable and Customary Fees: The average fee charged by a particular type of health care practitioner within a geographic area. The term is often used by medical plans as the amount of money they will approve for a specific test or procedure. If the fees are higher than the approved amount, the individual receiving the service is responsible for paying the difference. Sometimes, however, if an individual questions his or her physician about the fee, the provider will reduce the charge to the amount that the insurance company has defined as reasonable and customary.
Rider: A modification made to a Certificate of Insurance regarding the clauses and provisions of a policy (usually adding or excluding coverage).
Risk: The chance of loss, the degree of probability of loss or the amount of possible loss to the insuring company. For an individual, risk represents such probabilities as the likelihood of surgical complications, medications' side effects, exposure to infection, or the chance of suffering a medical problem because of a lifestyle or other choice. For example, an individual increases his or her risk of getting cancer if he or she chooses to smoke cigarettes.
S
Second Opinion: It is a medical opinion provided by a second physician or medical expert, when one physician provides a diagnosis or recommends surgery to an individual. Individuals are encouraged to obtain second opinions whenever a physician recommends surgery or presents an individual with a serious medical diagnosis.
Second Surgical Opinion: These are now standard benefits in many health insurance plans. It is an opinion provided by a second physician, when one physician recommends surgery to an individual.
Short-Term Disability: An injury or illness that keeps a person from working for a short time. The definition of
short-term disability (and the time period over which coverage extends) differs among insurance companies and employers. Short-term disability insurance coverage is designed to protect an individual's full or partial wages during a time of injury or illness (that is not work-related) that would prohibit the individual from working.
Short-Term Medical: Temporary coverage for an individual for a short period of time, usually from 30 days to six months.
State Mandated Benefits: When a state passes laws requiring that health insurance plans include specific benefits.
Stop-loss: The dollar amount of claims filed for eligible expenses at which which point you've paid 100 percent of your out-of-pocket and the insurance begins to pay at 100%. Stop-loss is reached when an insured individual has paid the deductible and reached the out-of-pocket maximum amount of co-insurance.
T
U
Underwriter: The company that assumes responsibility for the risk, issues insurance policies and receives premiums.
Usual, Customary and Reasonable (UCR) or Covered Expenses: An amount customarily charged for or covered for similar services and supplies which are medically necessary, recommended by a doctor, or required for treatment.
W
Waiting Period: A period of time when you are not covered by insurance for a particular problem.
A
Actuary: A mathematician working for a health insurance company responsible for determining what premiums the company needs to charge based in large part on claims paid verses amounts of premium generated. Their job is to make sure a block of business is priced to be profitable.
Admitting Privileges: The right granted to a doctor to admit patients to a particular hospital.
Agent: Licensed salespersons who represent one or more health insurance companies and presents their products to consumers.
Association: A group. Often, associations can offer individual health insurance plans specially designed for their members.
B
Benefit: Amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss.
Brand-name drug: Prescription drugs marketed with a specific brand name by the company that manufactures it, usually the company which develops and patents it. When patents run out, generic versions of many popular drugs are marketed at lower cost by other companies. Check your insurance plan to see if coverage differs between name-brand and their generic twins.
Broker: Licensed insurance salesperson who obtains quotes and plan from multiple sources information for clients.
C
Carrier: The insurance company or HMO offering a health plan.
Case Management: Case management is a system embraced by employers and insurance companies to ensure that individuals receive appropriate, reasonable health care services.
Certificate of Insurance: The printed description of the benefits and coverage provisions forming the contract between the carrier and the customer. Discloses what it covered, what is not, and dollar limits.
Claim: A request by an individual (or his or her provider) to an individual's insurance company for the insurance company to pay for services obtained from a health care professional.
Co-Insurance: Co-insurance refers to money that an individual is required to pay for services, after a deductible has been paid. In some health care plans, co-insurance is called "co-payment." Co-insurance is often specified by a percentage. For example, the employee pays 20 percent toward the charges for a service and the employer or insurance company pays 80 percent.
Related terms: Co-Payment, Deductible
Co-Payment: Co-payment is a predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers. For example, some HMOs require a $10 "co-payment" for each office visit, regardless of the type or level of services provided during the visit. Co-payments are not usually specified by percentages.
Related terms: Co-Insurance, Deductible
COBRA: Federal legislation that lets you, if you work for an insured employer group of 20 or more employees, continue to purchase health insurance for up to 18 months if you lose your job or your coverage is otherwise terminated. For more information, visit the Department of Labor.
Credit for Prior Coverage: This is something that may or may not apply when you switch employers or insurance plans. A pre-existing condition waiting period met under while you were under an employer's (qualifying) coverage can be honored by your new plan, if any interruption in the coverage between the two plans meets state guidelines.
D
Deductible: The amount an individual must pay for health care expenses before insurance (or a self-insured company) covers the costs. Often, insurance plans are based on yearly deductible amounts.
Related terms: Co-Insurance, Co-Payment
Denial Of Claim: Refusal by an insurance company to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional.
Dependents: Spouse and/or unmarried children (whether natural, adopted or step) of an insured.
E
Effective Date: The date your insurance is to actually begin. You are not covered until the policies effective date.
Exclusions: Medical services that are not covered by an individual's insurance policy.
Explanation of Benefits: The insurance company's written explanation to a claim, showing what they paid and what the client must pay. Sometimes accompanied by a benefits check.
G
Generic Drug: A "twin" to a "brand name drug" once the brand name company's patent has run out and other drug companies are allowed to sell a duplicate of the original. Generic drugs are cheaper, and most prescription and health plans reward clients for choosing generics.
Group Insurance: Coverage through an employer or other entity that covers all individuals in the group.
H
Health Maintenance Organizations (HMOs): Health Maintenance Organizations represent "pre-paid" or "capitated" insurance plans in which individuals or their employers pay a fixed monthly fee for services, instead of a separate charge for each visit or service. The monthly fees remain the same, regardless of types or levels of services provided, Services are provided by physicians who are employed by, or under contract with, the HMO. HMOs vary in design. Depending on the type of the HMO, services may be provided in a central facility, or in a physician's own office (as with IPAs.)
HIPAA: A Federal law passed in 1996 that allows persons to qualify immediately for comparable health insurance coverage when they change their employment or relationships. It also creates the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care. Full name is "The Health Insurance
Portability and Accountability Act of 1996."
I
In-network: Providers or health care facilities which are part of a health plan's network of providers with which it has negoiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts.
Indemnity Health Plan: Indemnity health insurance plans are also called "fee-for-service." These are the types of plans that primarily existed before the rise of HMOs, IPAs, and PPOs. With indemnity plans, the individual pays a pre-determined percentage of the cost of health care services, and the insurance company (or self-insured employer) pays the other percentage. For example, an individual might pay 20 percent for services and the insurance company pays 80 percent. The fees for services are defined by the providers and vary from physician to physician. Indemnity health plans offer individuals the freedom to choose their health care professionals.
Independent Practice Associations: IPAs are similar to HMOs, except that individuals receive care in a physician's own office, rather than in an HMO facility.
Individual Health Insurance: Health insurance coverage on an individual, not group, basis. The premium is usually higher for an individual health insurance plan than for a group policy, but you may not qualify for a group plan.
L
Lifetime Maximum Benefit (or Maximum Lifetime Benefit): the maximum amount a health plan will pay in benefits to an insured individual during that individual's lifetime.
Limitations: a limit on the amount of benefits paid out for a particular covered expense, as disclosed on the Certificate of Insurance.
Long-Term Care Policy: Insurance policies that cover specified services for a specified period of time. Long-term care policies (and their prices) vary significantly. Covered services often include nursing care, home health care services, and custodial care.
Long-term Disability Insurance: Pays an insured a percentage of their monthly earnings if they become disabled.
LOS: LOS refers to the length of stay. It is a term used by insurance companies, case managers and/or employers to describe the amount of time an individual stays in a hospital or in-patient facility.
M
Managed Care: A medical delivery system that attempts to manage the quality and cost of medical services that individuals receive. Most managed care systems offer HMOs and PPOs that individuals are encouraged to use for their health care services. Some managed care plans attempt to improve health quality, by emphasizing prevention of disease.
Maximum Dollar Limit: The maximum amount of money that an insurance company (or self-insured company) will pay for claims within a specific time period. Maximum dollar limits vary greatly. They may be based on or specified in terms of types of illnesses or types of services. Sometimes they are specified in terms of lifetime, sometimes for a year.
N
Network: A group of doctors, hospitals and other health care providers contracted to provide services to insurance
companies customers for less than their usual fees. Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less for using a network provider.
O
Open-ended HMOs: HMOs which allow enrolled individuals to use out-of-plan providers and still receive partial or full coverage and payment for the professional's services under a traditional indemnity plan.
Out-of-Plan (Out-of-Network): This phrase usually refers to physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan (usually an HMO or PPO). Depending on an individual's health insurance plan, expenses incurred by services provided by out-of-plan health professionals may not be covered, or covered only in part by an individual's insurance company.
Out-Of-Pocket Maximum: A predetermined limited amount of money that an individual must pay out of their own savings, before an insurance company or (self-insured employer) will pay 100 percent for an individual's health care expenses.
Outpatient: An individual (patient) who receives health care services (such as surgery) on an outpatient basis, meaning they do not stay overnight in a hospital or inpatient facility. Many insurance companies have identified a list of tests and procedures (including surgery) that will not be covered (paid for) unless they are performed on an outpatient basis. The term outpatient is also used synonymously with ambulatory to describe health care facilities where procedures are performed.
P
Pre-Admission Certification: Also called pre-certification review, or pre-admission review. Approval by a case manager or insurance company representative (usually a nurse) for a person to be admitted to a hospital or in-patient facility, granted prior to the admittance. Pre-admission certification often must be obtained by the individual. Sometimes, however, physicians will contact the appropriate individual. The goal of pre-admission certification is to ensure that individuals are not exposed to inappropriate health care services (services that are medically unnecessary).
Pre-Admission Review: A review of an individual's health care status or condition, prior to an individual being admitted to an inpatient health care facility, such as a hospital. Pre-admission reviews are often conducted by case managers or insurance company representatives (usually nurses) in cooperation with the individual, his or her physician or health care provider, and hospitals.
Pre-existing Conditions: A medical condition that is excluded from coverage by an insurance company, because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company.
Preadmission Testing: Medical tests that are completed for an individual prior to being admitted to a hospital or inpatient health care facility.
Preferred Provider Organizations (PPOs): You or your employer receive discounted rates if you use doctors from a pre-selected group. If you use a physician outside the PPO plan, you must pay more for the medical care.
Primary Care Provider (PCP): A health care professional (usually a physician) who is responsible for monitoring an individual's overall health care needs. Typically, a PCP serves as a "quarterback" for an individual's medical care, referring the individual to more specialized physicians for specialist care.
Provider: Provider is a term used for health professionals who provide health care services. Sometimes, the term refers only to physicians. Often, however, the term also refers to other health care professionals such as hospitals, nurse practitioners, chiropractors, physical therapists, and others offering specialized health care services.
R
Reasonable and Customary Fees: The average fee charged by a particular type of health care practitioner within a geographic area. The term is often used by medical plans as the amount of money they will approve for a specific test or procedure. If the fees are higher than the approved amount, the individual receiving the service is responsible for paying the difference. Sometimes, however, if an individual questions his or her physician about the fee, the provider will reduce the charge to the amount that the insurance company has defined as reasonable and customary.
Rider: A modification made to a Certificate of Insurance regarding the clauses and provisions of a policy (usually adding or excluding coverage).
Risk: The chance of loss, the degree of probability of loss or the amount of possible loss to the insuring company. For an individual, risk represents such probabilities as the likelihood of surgical complications, medications' side effects, exposure to infection, or the chance of suffering a medical problem because of a lifestyle or other choice. For example, an individual increases his or her risk of getting cancer if he or she chooses to smoke cigarettes.
S
Second Opinion: It is a medical opinion provided by a second physician or medical expert, when one physician provides a diagnosis or recommends surgery to an individual. Individuals are encouraged to obtain second opinions whenever a physician recommends surgery or presents an individual with a serious medical diagnosis.
Second Surgical Opinion: These are now standard benefits in many health insurance plans. It is an opinion provided by a second physician, when one physician recommends surgery to an individual.
Short-Term Disability: An injury or illness that keeps a person from working for a short time. The definition of
short-term disability (and the time period over which coverage extends) differs among insurance companies and employers. Short-term disability insurance coverage is designed to protect an individual's full or partial wages during a time of injury or illness (that is not work-related) that would prohibit the individual from working.
Short-Term Medical: Temporary coverage for an individual for a short period of time, usually from 30 days to six months.
State Mandated Benefits: When a state passes laws requiring that health insurance plans include specific benefits.
Stop-loss: The dollar amount of claims filed for eligible expenses at which which point you've paid 100 percent of your out-of-pocket and the insurance begins to pay at 100%. Stop-loss is reached when an insured individual has paid the deductible and reached the out-of-pocket maximum amount of co-insurance.
T
U
Underwriter: The company that assumes responsibility for the risk, issues insurance policies and receives premiums.
Usual, Customary and Reasonable (UCR) or Covered Expenses: An amount customarily charged for or covered for similar services and supplies which are medically necessary, recommended by a doctor, or required for treatment.
W
Waiting Period: A period of time when you are not covered by insurance for a particular problem.
How to Choose Your Health Insurance Provider
Choosing a health insurance provider can be a challenging, time consuming and frustrating activity. Insurance is just one of those things we all would rather not think about.
When you need to, choose carefully, because when the need for coverage does arise (and it will) be sure you have the right kind of coverage.
So, which provider and plan are right for you and your family?
Many people are disappointed to discover that health insurance is either not offered by their employer or that the coverage does not meet their needs. Some folks are self-employed and do not have access to employer provided benefits. If you are self employed or if your employer’s plan doesn’t meet your needs, choose your own health insurance provider!
Do some research with a professional insurance agent and compare what is offered by plans that you can get on your own. You may be surprised that you can get affordable coverage that is more appropriate for your family’s health circumstances.
When looking, consider the following:
Putting It All Together
Finally, review your notes and compare. Follow this process and you will be sure to find affordable and comprehensive coverage that will match your personal insurance needs. Remember to do this once every year or so. Plans change, get the best for the least to meet your needs.
When you need to, choose carefully, because when the need for coverage does arise (and it will) be sure you have the right kind of coverage.
So, which provider and plan are right for you and your family?
Many people are disappointed to discover that health insurance is either not offered by their employer or that the coverage does not meet their needs. Some folks are self-employed and do not have access to employer provided benefits. If you are self employed or if your employer’s plan doesn’t meet your needs, choose your own health insurance provider!
Do some research with a professional insurance agent and compare what is offered by plans that you can get on your own. You may be surprised that you can get affordable coverage that is more appropriate for your family’s health circumstances.
When looking, consider the following:
- First of all, are you eligible? Yes, you must qualify for health insurance.
- Will you be rated up as a result of a pre-existing condition?
- Be aware! Websites provide rates for “Preferred Clients” – people with excellent health. If you are taking any medication, you are likely to be charged more.
- If you have a pre-existing condition, how long before it is covered?
- What kind of a plan is it? HMO? PPO? HSA?
- Check out the terms used! See Glossary of Terms on this Blog.
- If it’s a PPO, what network? Is your doctor in the network? How big is the network?
- Is an HSA (Health Savings Account) offered? What are the details, if so?
- How much does it cost on a monthly basis? Are the rates fixed or variable?
- What is covered: Office visits? Accidents? Hospitalization? Prescriptions?
- How much does a plan cost without doctor visits? The difference may surprise you.
- Does it include dental, and vision?
- What kind of deductibles and co-payments are available? If you are older, consider a higher deductible.
- Must you make a commitment for more than 30 days?
- When are you able you modify your plan?
Putting It All Together
Finally, review your notes and compare. Follow this process and you will be sure to find affordable and comprehensive coverage that will match your personal insurance needs. Remember to do this once every year or so. Plans change, get the best for the least to meet your needs.
Monday, November 17, 2008
Power to Help Cut Your Health Care Costs
Health care costs are rising about 6 percent annually (health insurance premiums are increasing more!). This is true for those who have health insurance as well as the uninsured. The right kind of care at the right place can have a big impact on your bill.
* An unnecessary visit to an emergency room could cost eight times more than going to a doctor's office.
* Fifty percent of visits to the emergency room are unnecessary and patients could have been treated at a doctor's office.
* The average charge at the emergency room is $1,024.
* This drops to $194 at the urgent care center, and all the way to $140 at the doctor's office.
Informed patients save money and time by making better decisions. However, deciding when and where to go for care can be challenging. Ideally, you want to select the most inexpensive location that is also qualified to treat your problems.
There is a Web site that helps answer these important questions for free: www.freemd.com. FreeMD is a free service, written by doctors, that helps you make important health decisions. It is powered by a revolutionary computer program that analyzes more than 3,000 symptoms and injuries, across all age groups. FreeMD will provide you with answers to the following questions:
* What might be causing your symptoms?
* When should you see a doctor?
* Where should you seek care?
* What kind of a doctor should you see?
* What should you do to care for yourself?
At FreeMD.com, consumers visit a virtual doctor, who asks questions and pinpoints the problem. FreeMD explains what treatment is required and where to get it: an emergency room, an urgent care center, or a doctor's office. When possible, FreeMD provides instructions on how to treat a problem at home.
Remember, $1,024 for an emergency room visit or $194 at urgent care. The choice is yours and there are tools to help you make an informed choice.
* An unnecessary visit to an emergency room could cost eight times more than going to a doctor's office.
* Fifty percent of visits to the emergency room are unnecessary and patients could have been treated at a doctor's office.
* The average charge at the emergency room is $1,024.
* This drops to $194 at the urgent care center, and all the way to $140 at the doctor's office.
Informed patients save money and time by making better decisions. However, deciding when and where to go for care can be challenging. Ideally, you want to select the most inexpensive location that is also qualified to treat your problems.
There is a Web site that helps answer these important questions for free: www.freemd.com. FreeMD is a free service, written by doctors, that helps you make important health decisions. It is powered by a revolutionary computer program that analyzes more than 3,000 symptoms and injuries, across all age groups. FreeMD will provide you with answers to the following questions:
* What might be causing your symptoms?
* When should you see a doctor?
* Where should you seek care?
* What kind of a doctor should you see?
* What should you do to care for yourself?
At FreeMD.com, consumers visit a virtual doctor, who asks questions and pinpoints the problem. FreeMD explains what treatment is required and where to get it: an emergency room, an urgent care center, or a doctor's office. When possible, FreeMD provides instructions on how to treat a problem at home.
Remember, $1,024 for an emergency room visit or $194 at urgent care. The choice is yours and there are tools to help you make an informed choice.
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