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Solving the Puzzle of Health Insurance

Reviewing a health insurance plan for yourself or an older loved one isn’t at the top of everyone’s list, but it should be. If you are a caregiver or simply an advocate for yourself, it’s extremely important to understand the basics of your health insurance plan or one you are about to purchase. If you don’t, you or your loved one will end up with unexpected medical bills and quite possibly an insurance plan you wish you didn’t have.

In 2014, Health Care Reform requires every individual to have health insurance, with a few exceptions. If you want to find out how The Affordable Care Act will affect you, visit this link here www.healthcare.gov/how-does-the-affordable-care-act-affect-me/

Many of us choose health insurance plans without really knowing how good they are and we choose them based on basic coverage, the amount of the premiums and other out-of-pocket fees. Having a good health insurance plan will prevent you from facing medical bills that could put you into serious debt if in the event you develop a medical condition, disease or are injured.

Reviewing a health insurance plan isn’t exactly stimulating and can be very complex, but it could be one of the most important things you do for yourself or a loved one you care for. Why? Because at the times we need our coverage the most, we can find out that medical services or prescriptions are not covered and that they must be paid for out-of-pocket.

What a Good Health Insurance Plan Looks Like
A good health plan protects you from medical expenses you cannot afford. It offers you the most benefits for the lowest cost, meaning it covers doctor visits, hospitalizations, medications, labs, imaging tests and preventive care for the least amount of money you have to pay. If you choose a plan that excludes major benefit categories such as prescription drugs it might lower your premiums, but can end up costing you more in the long run.

You’ll want to understand the basics of your health insurance plan whether you get it from your employer, privately or receive Medicare, Medicaid or another form of public insurance. You can find information in the packet you received, on the health insurance plan’s website or you can call the customer service phone number and ask questions. You will also have the option to shop the Affordable Care Act’s new Marketplace (Health Insurance Exchanges) to compare and contrast health insurance plans. If you haven’t been able to obtain health insurance in the past, you will now. Starting on October 1, 2013, the marketplace will open online; coverage will start January 1, 2014.

You can use a health insurance agent or broker to help you choose the best plan for you and to assist with explanations of the various plans. If you decide to use an agent or broker, choose a professional with a good reputation in the industry, one who is referred by someone you trust.

Different Types of Health Insurance

1. Public Health Insurance

  • Medicare is healthcare insurance provided by the federal government. It is open to people age 65 and older and to younger people with disabilities. Medicare does not cover all medical expenses and enrollees have out-of-pocket costs; many services require a 20% co-pay.
  • Medicaid provides coverage for people under the age of 65 with lower incomes, older people, pregnant women, people with disabilities and some families and children. Eligibility rules differ from state to state.
  • CHIP provides health coverage to children and their families with incomes too high to qualify for Medicaid, but who can’t afford private insurance.
  • TRICARE is available to active duty service members and retirees of the uniformed services, their family members, survivors and others.
  • Veterans Administration is an integrated healthcare system that provides healthcare to veterans and some dependents.

2. Private Health Insurance

  • Preferred Provider Organizations (PPOs) contract with healthcare providers and negotiate preferential prices. PPOs generally give you greater freedom to choose doctors, surgery centers and hospitals.
  • Health Maintenance Organizations (HMOs) are generally the least expensive of health insurance plans. But there are a number of different types of HMOs, so get details before you choose. Different types can mean different things to your coverage. You may pay a set premium to the HMO or have a co-pay. You receive medical services from a set of doctors, hospitals and other medical facilities that are within your HMO. If you use non-authorized providers or receive non-authorized care, your HMO will not pay any portion of your bills. Your primary care physician is responsible for managing and coordinating your care—that usually means you'll need a referral for other services and specialists.
  • Point of Service Plans (POS) are a hybrid of a PPO and an HMO. You can choose to have a primary care physician coordinate your care or opt to go directly with fee-for-service.

10 Important Questions to Ask Your Health Insurance Provider
Finding out the answers to the following questions will prevent what happens to many of us--when we are in need we discover that our plan doesn’t cover the medical provider, hospital, prescription medications, anesthesiologist or surgery center of our choice.

Even if you already have health insurance, find out the answers to these questions:

  1. Is my doctor, hospital or surgery center of my choice covered by my plan?
  2. Is my medication covered by my plan?
  3. Does the plan cover my specific needs such as a specialist, vision, dental, chemotherapy and more?
  4. Are referrals required for additional services?
  5. Are my existing doctors, hospital or surgery center in-network or out-of-network? In-network means lower out of pocket expenses to you because your insurance plan is contracted with your doctor or hospital. Out-of-network means increased fees you’ll be responsible for since your doctor or hospital is not contracted with your plan.
  6. What is my premium? This is the amount of money you pay for your insurance plan on a regular basis. If you get health insurance from your employer, your premium may be deducted from your paycheck. If you purchase your own health insurance plan, you may have the option of paying your premium annually, quarterly or monthly.
  7. What are my co-pays? You pay a fixed dollar amount when a medical service is received. The insurer is responsible for the rest of the reimbursement, depending on your plan.
  8. What is my co-insurance? You may have to pay a percentage of medical expenses after the deductible amount is met.
  9. What is my deductible? This is a fixed dollar amount that you pay before your health insurance starts to make payments for covered medical services. For example, if you have a $3,500 deductible, you have to reach that limit before your health plan pays for medical services during a calendar year.
  10. What is my out of pocket maximum? This is the maximum amount of money you pay annually. This is important because it limits the total amount you pay each calendar year.