
If you don’t have group-based health insurance such as the one typically provided by your employer, you may be shopping for individual or family health insurance. To make an informed decision, you need to understand the different kinds of options available to you.
Part I: Types of Individual/Family Health Insurance Plans
Traditional Health Insurance Plans
Indemnity Plan / Fee-for-Service Plan / Major Medical Health Plan
Health insurance used to be very much like any car insurance today. You paid your premiums and in exchange you were covered for any amount above your deductible. This type of health insurance is known as an indemnity plan. Today it is also known as fee-for-service insurance or major medical health insurance.
Under a traditional plan, you can go to any doctor or hospital you want anytime. Your insurance coverage is the same everywhere. Unfortunately, you will have to pay more for this degree of flexibility. Traditional plans are the most expensive type of health insurance.
As the cost of medical care has risen rapidly over the last few decades, health insurance providers have turned to managed care plans in order to lower their expenses.
Managed Care Health Insurance Plans
These days, the majority of people with private health insurance are covered by a managed care plan. The three most common types of managed care include HMO, PPO, and POS plans. In addition to these long-term plans, there are also short -term health insurance plans.
Health Maintenance Organization (HMO)
A Health Maintenance Organization (HMO) is a network of hospitals, doctors, labs, etc. that have agreed to charge lower fees to HMO members. These lower rates come at a price. As an HMO member you are assigned a primary care physician (PCP), who acts as a gatekeeper. Unless you have an emergency, you have to see your PCP first for all your medical care needs. If they think you need a specialist, they will refer you to a specialist within the HMO network. Note that the HMO will not reimburse you for visits to doctors outside of their network.
Preferred Provider Organization (PPO)
With a Preferred Provider Organization (PPO), you are not required to choose a primary care physician (PCP), and you don’t need a PCP referral when you need to see a specialist. You can see any specialist you choose. However, this added flexibility comes with higher costs. Most PPPs require higher copayments or coinsurance and often require you to pay a deductible before they start paying for any of your expenses. At the same time, the PPO also provides a financial incentive for you to stay within their network. The PPO has contracts with healthcare providers to charge lower fees for their services. When you go out of that network, you typically have to pay more. For example, your co-pay may be $50 instead of $30. In addition, an out-of-network doctor may require you to pay the entire bill up front. You will then have to submit paperwork to the PPO in order to get reimbursed. Consequently, most people who are covered by a PPO stick with in-network doctors.
Point-of-Service (POS)
A Point-of-Service plan is a like a cross between a PPO and an HMO. It is similar to a PPO in that it offers you the flexibility to choose between in-network and out-of-network providers. However, similar to an HMO, you are assigned a primary care physician (PCP). If you want to see a specialist, you will need a referral from your PCP. Your PCP is likely to refer you to an in-network doctor. If you insist on seeing an out-of-network doctor, you will have to complete more paperwork and accept a much smaller reimbursement from your insurance. In line with its relative flexibility, the cost of a POS is usually between that of an HMO and a PPO.
Part II: Long-Term Plans vs. Short-Term Plans
Most people opt for long-term health insurance, which allows you to renew your plan every year as long as you keep paying your premiums. This is to your advantage because your insurance company won’t just be able to cancel your insurance on you just because they feel you are costing them too much. At the same time, this added risk is priced into the premiums that long-term plan members have to pay.
With short-term plans, on the other hand, this risk is significantly reduced. The chance that you could fall sick within a short period is minimal and thus the cost of insurance is lower too. Short-term plans are usually for 6 months. Many of these plans give you the option of renewing your policy for up to 36 months, but each new plan is considered to be a completely new policy. Most short-term plans are either PPOs or indemnity plans. They allow you to see any health care provider you like but come with deductible and coinsurance terms.
The major disadvantage of a short-term plan is the risk that you may not be able to renew it and end up without coverage. This can happen easier than you think. If you are diagnosed with a medical condition, they may consider that to be a preexisting condition and deny you coverage when you try to renew your policy less than six months later.
Nevertheless, if you lost your employer-based healthcare and you can’t afford a long-term plan, then a cheap short-term plan may be your only option. If you have a preexisting condition such as diabetes, you need to make sure that you keep some sort of health insurance until you find another job at which point you can re-enroll in your employer-based group plan. Because of the Health Insurance Portability and Accountability Act (HIPAA), your new employer-based group will usually have to accept you despite your preexisting condition. However, you lose this important protection if you are without health insurance for more than 63 days in the preceding 12 months.
Part III: Important Terminology
Deductible
A deductible is a specific dollar amount that your health insurance requires you to pay each year out of your own pocket before they start paying for any of your medical expenses. As a general rule, most HMOs do not require a deductible while traditional health insurance, PPOs, and POS plans do.
Coinsurance
Co-insurance is a cost-sharing requirement between you and your health insurance. After you have fully paid your annual deductible, you also have to pay a share of the remaining costs of your medical care. Your share is expressed as a percentage. For example, when you’re coinsurance is 20%, you pay 20% and your insurance will pay for 80% of the covered medical expenses. The amount of covered medical expenses you have to pay for yourself is limited only by your out-of-pocket limit for the year.
Out-of-pocket limit
The out-of-pocket limit is the maximum amount you will have to pay each year for covered medical expenses. The out-of-pocket limit takes into account your deductible as well as your coinsurance payments.
Lifetime maximum
A lifetime maximum is the maximum amount your insurance will pay for expenses during your lifetime.
Copayment
Some plans require a copayment, or copay, which means you pay a flat fee for each medical service and your insurance will pay for the rest. For example, a co-pay arrangement may require you to pay $20 for each office visit or $50 for a hospital stay.
Medically necessary treatments or services
Your health insurance will only cover medical expenses for treatments or services that are deemed medically necessary. For example, they may deny payment for treatments that are considered cosmetic.
Reasonable and customary charges
Your health insurance will only pay what it considers reasonable and customer charges.
Preexisting conditions
A health insurance will not pay for health problems that were diagnosed before the effective date of the insurance. If you have job-based coverage, you may be excluded from coverage only for a limited time such as a year. If you’re on an individual or family plan, your options are much more limited. In fact, you may be unable to get health insurance because of your preexisting condition.
Part IV: How to Shop for Health Insurance
1. COBRA. Employer-based group-based coverage is cheaper than individual/family plans. If you lost your employer-based coverage because you lost your job, the Consolidated Omnibus Budget Reconciliation Act (COBRA) allows you to stay enrolled in that plan for up to 18 months. Although you will have to pay the full premium, including the portion previously paid for by your employer, it will still be cheaper than getting similar coverage under an individual policy.
2. Decide on a type of plan. Decide what kind of plan you want: HMO, PPP, POS, or short-term health insurance.
3. Compare multiple insurance plans. Find out about the various types of plans offered by at least five different insurance companies. Aetna, Kaiser, Blue Cross, and Blue Shield are among the insurance providers that can be found in almost every state. You can visit their websites to view the plans they offer. In most cases, you can even request to have a brochure mailed to your home. In addition, U.S. News & World Report publishes a list of the best commercial health plans, which you can use to find more reputable health plans. When you compare the policies, you will need to weigh the monthly premiums they charge vs. any deductibles, coinsurance, copayment, and out-of-pocket requirements. Also, ask for how long the premiums are guaranteed. You don’t want to fall for an introductory offer.
4. Beware of fake insurance. In your search for the cheapest policy out there, you may fall victim to a company selling fake health insurance. It’s more common that you think. Be sure to check the website of the National Association of Insurance Commissioners for a list of licensed insurance companies.
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