Unless you are a millionaire and can pay for health services out of your own pocket, buying health insurance is crucial. The right time to make such a purchase is before an accident happens, you get seriously ill, or you find out you’re pregnant.
Individual health insurance does not cover expenses related to treating medical problems or conditions that originated prior to the purchase of the insurance policy, although there are now Health Insurance Policies that cover Preconditions through the government. Searching for adequate coverage can be a bit overwhelming, but getting acquainted with the basics can make the process easier and make the task less difficult.
Most of the information you will find below will change in the coming months and years as a result of the health system reform laws coming into force. Here you will find a calendar on the reform of the health system.
The contracting company does not have to provide you with health insurance
There are no state or federal laws that require private employers to provide health benefits to their employees. However, many companies offer health insurance and health benefits to their employees to attract and keep workers. When group health insurance is offered, they are then subject to a whole series of state mandates on what type of benefits are to be included, unless the employer is self-insured (in which case the employer itself covers the costs of claims, and not an insurance company).
Even though health insurance mandates provide broader coverage, they can cause prices to skyrocket. For example, the Council for Affordable Health Insurance (CAHI) estimates that adding birth control costs increases the cost of a group insurance policy by 1 to 3 percent. See the CAHI list of state mandates on health insurance benefits.
State mandated benefits do not apply to individual (private sector) policies that you purchase on your own.
Closing the gap with insurance
The federal COBRA (Consolidated Collective Budget Reconciliation Act) law could provide you with the much-needed guarantee of short-term protection. COBRA allows the worker to continue with group health insurance coverage if he loses his job, as long as you pay the full premium and a small amount for administration expenses. The law is enforced in companies with 20 or more employees and usually lasts 18 months.
Buying continuity coverage through COBRA is not cheap. For more information visit Know Your COBRA Rights.
Another federal law that provides some protection for employees when they switch from one group insurance policy to another is HIPAA (Health Insurance Portability and Accountability Act). HIPAA imposes limits to the extent that some group insurance policies may deny coverage based on pre-existing conditions. For example, if you have had creditable health insurance coverage for 12 consecutive months, without termination of coverage for more than 63 days, the new group insurance policy cannot deny you pre-existing conditions. The new policy should cover all your medical problems immediately, as soon as you enroll.
As an alternative to obtaining health insurance in the transition period from one group insurance policy to another, there is the contracting of short-term medical insurance and main medical insurance.
Health Insurance Guide
If you can’t access group health insurance through work, you should look for a private health insurance policy (known as an individual health insurance policy). Unlike group group policies, in which health-related expenses and risks extend to the group as a whole, individual health insurance policies are “clinically insured” to consider your personal medical history, profession, age, and gender. . Any “pre-existing” condition, such as heart disease, diabetes, and even pregnancy can cause rejection when accepted or increase insurance premiums. Some states require insurance companies that offer individual coverage policies to provide each individual with a policy, regardless of their health status,
Once you’ve got an individual health insurance policy, you can’t expect premiums to stay the same. Insurance companies often seek authorization to raise premiums. Some states also allow insurance companies to “file and use” the rate hike, which means that insurance companies simply submitting the increases in writing can immediately start charging more. Unless state supervisors consider the rates to be excessive, insurance companies can continue to charge higher premiums.
If you are a college student and need coverage, the college you are enrolled in may offer reasonably priced health insurance. Visit the page with information about medical insurance policies for university students.
No matter your age, there are several federally subsidized programs to help you if you cannot afford an individual policy franchise, as long as you meet the specific requirements.
A health insurance program for people 65 and older, certain young people with disabilities, and people who are terminally ill with kidney disease.
Medicaid : A program for the poorest individuals and low-income families with children.
State Children’s Health Insurance Program (SCHIP) : Policies that provide health coverage to children whose parents earn too much to qualify for Medicaid but who earn too little to afford individual health insurance. In some states, SCHIP policies include parents and pregnant women.
How to make sense of the alphabet soup
There are several options when choosing health insurance, whether you are looking for health insurance with individual coverage or group coverage, such as traditional policies based on the service provided (FFS), from health maintenance organizations (HMOs) ), Point of Service (POS) and Preferred Provider Organizations (PPOs).
Each of the plans has characteristics to contrast before deciding on one. HMOs, PPOs, and POS plans are grouped under the category “managed health plans,” which focus on cost-effective health care.
Service-based plans (FFS), also called compensation
FFS offers flexible coverage for higher out-of-pocket costs, more paperwork, and higher premiums.
Advantages of FFS
You can choose your own doctors and hospitals. There is no service network.
You can go to any specialist without the permission of the family doctor (PCP).
Most FFS plans have a limit, a maximum cap to pay on medical bills in a year. You reach that cap when the sum of all out-of-pocket expenses (franchises and coinsurance) reaches a certain amount. Thereafter the insurance company covers 100% of the expenses of everything covered in your policy. The limit amount does not include your insurance premium.
Disadvantages of FFS
There is usually a franchise to pay (from $ 500 to $ 1,500) before the insurance company begins to pay medical bills, and when they do, doctors will pay 80 percent of the bill and you will cover 20 for remaining hundred. Your portion is called coinsurance.
You may have to pay in advance for medical expenses and then submit the bill and be reimbursed. To receive your payment, you must fill out forms and send them to the insurer, or find a doctor who is willing to do it for you. You should also save receipts for medications and other medical expenses.
FFS plans cover “usual and reasonable” medical expenses. If your doctor charges more than the average according to your area, you will have to pay the difference.
Not all medical expenses you may have count as part of the franchise. Only those expenses that are covered by your policy.
Health Maintenance Organizations (HMOs)
HMOs tend to be the cheapest in terms of insurance premiums, but they are also the least flexible of all health insurance plans. The primary focus of the HMO is to reduce medical expenses through an increase in preventive medicine services. HMOs are designed to maintain the health of the individual as well as to provide them with adequate medical care following an illness or injury.
They offer low copays, minimal paperwork, and coverage for many preventive medicine and health improvement programs.
HMO plans often offer a wide selection of doctors and hospitals.
Participants in this plan pay a small fee (or copayment), usually about $ 15 to $ 20, for each medical visit to a doctor who is in the HMO’s network of services.
Basic medical services with an HMO typically include physician-provided services, outpatient services, medical treatment, short-term mental health services, and outpatient / inpatient emergency visits.
Disadvantages of HMO
You must choose a family doctor (PCP).
If your doctor is not included in the plan, you will need to obtain special permission and pay a higher proportion of the visit costs or pay the total cost of treatment with that doctor.
HMOs require you to visit the doctors included in their network of services, otherwise you will have to pay most or all of the bill.
The HMO directly or indirectly controls the amount of healthcare the doctor is allowed to provide you.
You must get a referral from the family doctor to see a specialist.
If you require laboratory tests and do not go to a laboratory doctor who participates in the service network, you will not be reimbursed for laboratory expenses.
If your regular doctor stops being part of the service network, you should find another who participates in the plan or pay higher prices to continue with it.
Point of Service Plans (POS)
POS plans are more flexible than HMOs, but they also require that you choose a family doctor. A POS plan combines the care aspects of an HMO with the freedom of choice of traditional health insurance. Sometimes HMOs include a POS plan to use for out-of-network benefits.
The POS plan provides a network of health care providers available to participants in that plan for a small fee or copayment, but in the event of illness or injury, the patient may choose a doctor from outside the network of services. Then you request that the POS plan reimburse you for the expenses.
Under your insurance company’s rules, you can decide to go to a doctor that is not part of the service network and be covered – but the amount the company covers is much less than if you went to a doctor that is included in the plan.
POS plans tend to offer more preventive medicine and wellness services, such as smoking cessation workshops and discounts for attending the gym.
Disadvantages of POS
You must choose a family doctor.
Preferred Provider Organization (PPO) Plans
PPOs offer financial incentives to policyholders – reasonable copays – to make use of participants in the plan’s service network.
The standard copay is $ 10 for a routine visit during normal operating hours.
You can access a specialist without prior permission, as long as the doctor is part of the service network.
Disadvantages of PPO
If you are seen by a doctor from outside the service network, you may have to pay the entire bill to provide it later and be reimbursed.
The PPO franchise is usually the highest. In 2008, the franchise average for an individual coverage policy in a PPO was $ 1,000, $ 500 above the 2007 amount, and $ 250 from the 2000 amount, according to survey data collected by Mercer, a resource consulting company. humans.
You may have to pay an excess if you decide to receive assistance outside the service network, or pay the difference between what the doctors included in the network of services charge and those who are not included in the network.
PPO policies may charge higher copays than specified in your policy if your doctor charges more than is considered “normal and reasonable”
How to find an individual health insurance policy
The first step you should take when looking for medical coverage is to compare coverage options and price offers online or through an insurance agent in your area.
You should tell your insurance agent what your specific health coverage needs are. Think carefully about the coverage you need. Is your doctor within the policy’s service network? What would be the out-of-pocket costs for a routine checkup? How much would you have to pay from your account in case of hospitalization? Does it include routine pediatric visits? Do you need me to cover prescription drugs? And also dental coverage ?.