A Health insurance policy is a contract between an insurance company and an individual. The contract can be renewable annually or monthly. The type and amount of health care costs that will be covered by the health plan are specified in advance, in the member contract or Evidence of Coverage booklet. The individual policy-holder's payment obligations may take several forms
1.Premium: The amount the policy-holder pays to the health plan each month to purchase health coverage.
2.Deductible: The amount that the policy-holder must pay out-of-pocket before the health plan pays its share. For example, a policy-holder might have to pay a $500 deductible per year, before any of their health care is covered by the health plan. It may take several doctor's visits or prescription refills before the policy-holder reaches the deductible and the health plan starts to pay for care.
3.Copayment: The amount that the policy-holder must pay out of pocket before the health plan pays for a particular visit or service. For example, a policy-holder might pay a $45 copayment for a doctor's visit, or to obtain a prescription. A copayment must be paid each time a particular service is obtained.
4.Coinsurance: Instead of paying a fixed amount up front (a copayment), the policy-holder must pay a percentage of the total cost. For example, the member might have to pay 20% of the cost of a surgery, while the health plan pays the other 80%. Because there is no upper limit on coinsurance, the policy-holder can end up owing very little, or a significant amount, depending on the actual costs of the services they obtain.
5.Exclusions: Not all services are covered. The policy-holder is generally expected to pay the full cost of non-covered services out of their own pocket.
6.Coverage limits: Some health plans only pay for health care up to a certain dollar amount. The policy-holder may be expected to pay any charges in excess of the health plan's maximum payment for a specific service. In addition, some plans have annual or lifetime coverage maximums. In these cases, the health plan will stop payment when they reach the benefit maximum, and the policy-holder must pay all remaining costs.
7.Out-of-pocket maximums: Similar to coverage limits, except that in this case, the member's payment obligation ends when they reach the out-of-pocket maximum, and the health plan pays all further covered costs. Out-of-pocket maximums can be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year
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November 16, 2007
Health Insurance.
Health insurance is a form of group insurance, where individuals pay premiums or taxes in order to help protect themselves from high or unexpected healthcare expenses. Health insurance works by estimating the overall "risk" of healthcare expenses and developing a routine finance structure (such as a monthly premium, or annual tax) that will ensure that money is available to pay for the healthcare benefits specified in the insurance agreement. The healthcare benefit is administered by a central organization, which is most often either a government agency, or a private or not-for-profit entity operating a health plan.
November 2, 2007
10 Areas of a Health Insurance Plan
What do you really need to know when deciding which health insurance plan is appropriate for you? While the information is most times segmented into individual, family or group coverage, there are many other factors that impact your insurance selection. Selecting the wrong plan can leave you under-insured and resulting in catastrophic loss when hit with a major medical issue. Review these 10 areas to know what to look for in your health insurance plan.
1) Prescription drug coverage - Depending upon the type of insurance plan you select, you will want to know if you will be adequately covered. Especially if you are already taking prescription medication on a regular basis, you will want to know which drugs are covered. In most cases, you will want a plan which includes co-pays and includes the ability to choose between generic or brand name. If you are prescribed a newer or experimental drug, you will need to do some research as many companies won't cover these costs.
2) Preventive services costs - these include services like annual exams, tests and screening including routine immunizations. Many times services like these are also on a co-pay system. Besides knowing what type of service is covered, you'll also want to know how much you'll have to pay.
3) Office visits - these include visits that are not covered under preventive services. One thing you'll want to find out is if you'll be able to use your regular doctors. If you currently use an HMO, you may only have the choice of participating providers. If you are using a PPO, you are normally free to consult with any doctor. In most cases, you can check to see if your doctor is covered under your plan before you buy.
4) Imaging and laboratory services - these include testing and interpretation of results for services like CAT scans, MRIs and x-rays. Many plans include a discount program where you get these services at a discount rate when used by an independent company such as Lab One.
5) Outpatient services - these include in-and-out services that do not typically require a hospital stay. They cover facility costs and the costs of supplies that you would need during your treatment.
6) Emergency room services - these include the use of services and supplies for the emergency room. This may or may not include ambulance services and supplies. Most plans charge an access fee to use the emergency room unless you are admitted.
7) Health care practitioner services - these include the services of a specialist such as surgeons, anesthesiologists, assistants and nurses. Besides costs, you'll also want to know how easy it will be to see a specialist. Will you have the flexibility of choosing a doctor on your own or will you need to have a referral.
8) Outpatient physical medicine - these include things like physical, speech and occupational therapies as well as rehabilitation services including chiropractic care.
9) Inpatient hospital - these include the use of hospital care - room and services as well as supplies and equipment.
10) Other services - these vary greatly from plan to plan and carrier to carrier. These services may include dental, vision, other specialized care and surgery, behavioral health and substance abuse and home care.
One other major factor that wasn't mentioned earlier was that of the overall plan costs. These costs include annual premiums, umbrella deductibles as well as embedded deductibles. When planning for your annual medical expenses, you'll need to estimate the cost of your premiums as well as any co-pays or non-covered payments that you might have to make. In addition, you'll also need to keep track of the umbrella and embedded deductibles to make sure you still have adequate coverage throughout the year.
Review these 10 areas to insure you properly review your health plan coverage. You'll also want to review your plan at least annually to ensure it provides what you need.
Copyright by Jack Morgan
1) Prescription drug coverage - Depending upon the type of insurance plan you select, you will want to know if you will be adequately covered. Especially if you are already taking prescription medication on a regular basis, you will want to know which drugs are covered. In most cases, you will want a plan which includes co-pays and includes the ability to choose between generic or brand name. If you are prescribed a newer or experimental drug, you will need to do some research as many companies won't cover these costs.
2) Preventive services costs - these include services like annual exams, tests and screening including routine immunizations. Many times services like these are also on a co-pay system. Besides knowing what type of service is covered, you'll also want to know how much you'll have to pay.
3) Office visits - these include visits that are not covered under preventive services. One thing you'll want to find out is if you'll be able to use your regular doctors. If you currently use an HMO, you may only have the choice of participating providers. If you are using a PPO, you are normally free to consult with any doctor. In most cases, you can check to see if your doctor is covered under your plan before you buy.
4) Imaging and laboratory services - these include testing and interpretation of results for services like CAT scans, MRIs and x-rays. Many plans include a discount program where you get these services at a discount rate when used by an independent company such as Lab One.
5) Outpatient services - these include in-and-out services that do not typically require a hospital stay. They cover facility costs and the costs of supplies that you would need during your treatment.
6) Emergency room services - these include the use of services and supplies for the emergency room. This may or may not include ambulance services and supplies. Most plans charge an access fee to use the emergency room unless you are admitted.
7) Health care practitioner services - these include the services of a specialist such as surgeons, anesthesiologists, assistants and nurses. Besides costs, you'll also want to know how easy it will be to see a specialist. Will you have the flexibility of choosing a doctor on your own or will you need to have a referral.
8) Outpatient physical medicine - these include things like physical, speech and occupational therapies as well as rehabilitation services including chiropractic care.
9) Inpatient hospital - these include the use of hospital care - room and services as well as supplies and equipment.
10) Other services - these vary greatly from plan to plan and carrier to carrier. These services may include dental, vision, other specialized care and surgery, behavioral health and substance abuse and home care.
One other major factor that wasn't mentioned earlier was that of the overall plan costs. These costs include annual premiums, umbrella deductibles as well as embedded deductibles. When planning for your annual medical expenses, you'll need to estimate the cost of your premiums as well as any co-pays or non-covered payments that you might have to make. In addition, you'll also need to keep track of the umbrella and embedded deductibles to make sure you still have adequate coverage throughout the year.
Review these 10 areas to insure you properly review your health plan coverage. You'll also want to review your plan at least annually to ensure it provides what you need.
Copyright by Jack Morgan
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