Guide to Health Insurance
But be sure to enroll in Medicare Part A, which covers hospitalization and can supplement your group coverage at no additional cost to you. You can save on Medicare premiums by not enrolling in Medicare Part B until you finally retire. Bear in mind, though, that delayed enrollment is more expensive and entails a waiting period for coverage.
Q I’ve had a serious health condition that appears to be stabilized. Can I buy individual health coverage?
A Depending on what your condition is and when it was diagnosed and treated, you can probably buy health coverage. However, the insurer may do one of three things:
-
provide full protection but with a higher premium, as might be the case with a chronic disease, such as diabetes;
-
modify the benefits to increase the deductible;
-
exclude the specific medical problem from coverage, if it is a clearly defined condition, as long as the insurer abides by state and federal laws on exclusions.
Q One of my medical bills was turned down by the insurance company (or health plan). Is there anything I can do?
A Ask the insurance company why the claim was rejected. If the answer is that the service isn’t covered under your policy, and you’re sure that it is covered, check to see that the provider entered the correct diagnosis or procedure code on the insurance claim form. Also check that your deductible was correctly calculated.
Make sure that you didn’t skip an essential step under your plan, such as pre admission certification. If everything is in order, ask the insurer to review the claim.
Comparing Plans
Whether you end up choosing a fee-for-service plan or a form of managed care, you must examine a benefits summary or an outline of coverage—the description of policy benefits, exclusions, and provisions that makes it easier to understand a particular policy and compare it with others.
Look at this information closely. Think about your personal situation. After all, you may not mind that pregnancy is not covered, but you may want coverage for psychological counseling. Do you want coverage for your whole family or just yourself? Are you concerned with preventive care and checkups? Or would you be comfortable in a managed care setting that might restrict your choice somewhat but give you broad coverage and convenience? These are questions that only you can answer.
Here are some of the things to look at when choosing and comparing health insurance plans.
Health Insurance Checklist
Covered medical services
- Inpatient hospital services
- Outpatient surgery
- Physician visits (in the hospital)
- Office visits
- Skilled nursing care
- Medical tests and X-rays
- Prescription drugs
- Mental health care
- Drug and alcohol abuse treatment
- Home health care visits
- Rehabilitation facility care
- Physical therapy
- Speech therapy
- Hospice care
- Maternity care
- Chiropractic treatment
- Preventive care and checkups
- Well-baby care
- Dental care
- Other covered services
Are there any medical service limits, exclusions, or preexisting conditions that will affect you or your family?
What types of utilization review, pre authorization, or certification procedures are included?
Costs
How much is the premium?
$_____________________________________________
q month q quarter q year
Are there any discounts available for good health or healthy behaviors (e.g., non-smoker)?
__________________________________________________________________
How much is the annual deductible?
$_________________________________ per person
$_________________________________ per family
What coinsurance or copayments apply?
_________________________________% after I meet my deductible
$_________________________________copay or % coinsurance per office visit
$_________________________________copay or % coinsurance for "wellness" care (includes well-baby care, annual eye exam, physical, etc.)
$_________________________________% copay or coinsurance for inpatient hospital care
Other Forms of Health Insurance
In addition to broad coverage for medical, surgical, and hospital expenses, there are many other kinds of health insurance.
Hospital-surgical policies, sometimes called basic health insurance, provide benefits when you have a covered condition that requires hospitalization. These benefits typically include room and board and other hospital services, surgery, physicians’ non surgical services that are performed in a hospital, expenses for diagnostic X-rays and laboratory tests, and room and board in an extended care facility.
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