Monthly Archives: June 2018

Health Insurance Terms and Definitions

One of the biggest problems for most people is simply understanding the health insurance benefits that they have. For the most part, health insurance policies try to be user-friendly in their wording, but many people are just not familiar with medical and insurance terminology.

Most health insurance policies also provide something similar to a cheat sheet which gives the basic outline of policy coverage and covers the most common medical services. However, you need to be sure that you understand the different things that are excluded under your plan. Many health insurance plans provide limited benefits for services such as mental health, chiropractic services, and occupational health. Even physical therapy and home health care are often limited to a certain number of visits per year.

Co-payment or Co-pay

A co-payment is a pre-determined amount that you must pay a medical provider for a particular type of service. For example, you may be required to pay a $15 co-payment when you visit your doctor. In this instance, you must pay $15 to the doctor’s office at the time of the visit. Normally, you are not required to pay any additional fees — your health insurance company will pay the rest. However, in some cases, if your health insurance policy specifies it, you may be responsible for a co-payment and then a percentage of the remaining balance.

Deductible

A deductible is the amount of your medical expenses you must pay for before the health insurance company will begin to pay benefits. Most health insurance plans have a calendar-year deductible which means that in January of every new year the deductible requirement starts over again. So, if your calendar year deductible is $1500, as long as your medical expenses for the current year do not exceed $1500 the insurance company pays nothing for that year. Once January of the new year starts, you have to begin again to pay for $1500 of your own medical expenses.

Coinsurance

Coinsurance (or out-of-pocket expense) is the amount or percentage of each medical charge that you are required to pay. For example, you may have a $100 medical charge. Your health insurance company will pay 80% of the charge and you are responsible for the additional 20%. The 20% is your coinsurance amount.

Coinsurance accrues throughout the year. If you have a large number of medical charges in one year, you may meet the coinsurance maximum requirement for your policy. At that point, any covered charges will be paid at 100% for the remainder of the calendar year.

Stop loss or out-of-pocket expense limit

Sometimes you will hear the out-of-pocket expense limit referred to as your stop loss or coinsurance amount. Basically, this is the amount you will need to pay out of your own pocket per calendar year before the health insurance company pays everything at 100%.

You will need to check your policy because many policies that require co-payments do not allow these co-payments to go toward the out-of-pocket amount. For example, you may have reached your out-of-pocket maximum for the year, so if you are admitted to the hospital you may pay nothing. However, since you have to pay a $15 co-payment every time you visit the doctor, you will still have to make this co-payment.

Lifetime maximum benefit

This is the maximum amount that the health insurance company will pay toward your medical expenses for the lifetime of your policy. Generally, this amount is in the millions of dollars. Unless you have a very severe condition, you will not likely exhaust this amount.

Preferred Provider Organization

A Preferred Provider Organization (also known as a PPO) is a group of participating medical providers who have agreed to work with the health insurance company at a discounted rate. It’s a win-win situation for each side. The insurance company has to pay less money and the providers receive automatic referrals.

In most health insurance policies, you will see different benefit levels depending on whether you visit a participating or nonparticipating provider. A PPO plan provides more flexibility for the insured person because they can visit either a participating or nonparticipating provider. They just receive a better price if they use a participating one.

Health Maintenance Organization

A Health Maintenance Organization (also known as an HMO) is a health insurance plan which restricts you to only using specified medical providers. Generally, unless you are out of the area of their network, no benefits are payable if you go to a nonparticipating physician. Typically, you are required to select one main doctor who will be your Primary Care Physician (PCP). Any time you have a health problem, you must visit this doctor first. If they feel that you need it, they will refer you to another network provider. However, you cannot just decide on your own to visit a specialist; you must go through your PCP.

Medically necessary

You will see this term in all health insurance policies, and it is a frequent cause of denied claims. Most insurance companies will not cover any expenses that they do not consider medically necessary. Just because you and/or your doctor consider something medically necessary, your health insurance company may not. For this reason, you always need to verify that any costly procedures you are considering will be covered.

Routine treatment

Routine treatment is generally defined as preventive services. For example, a yearly physical examination that you have on a regular basis is generally considered to be routine. Many of the immunizations that children and adults receive fall under this classification. Some insurance companies provide limited coverage for routine treatment; others provide no benefits at all.

Pre-existing condition

A pre-existing condition is a condition that you acquired and/or received treatment for prior to the effective date of your current health insurance policy. Health insurance companies vary on how they treat pre-existing conditions. Some companies will not give you coverage at all if you have certain chronic pre-existing conditions. Others will give you coverage but will not provide any benefits for a period of time — usually from 12-24 months. Still, other health insurance companies will specifically exclude a pre-existing condition from a policy and will never provide any benefits for that condition.

Be sure that you are very clear on the pre-existing limitations of your policy so that you are not unpleasantly surprised when you visit your doctor.

Explanation of Benefits

This is the form that the health insurance company sends you after they complete the handling of your claim. It details the bill they received and how they processed it. It is commonly called an EOB.

Coordination of Benefits

If you are eligible for benefits under more than one health insurance plan, your various health insurance companies will need to coordinate benefits. This insures that no more than 100% of the total charge is paid. There are many variations on how this situation can occur. In general, the primary company makes their payment first. Then you file a copy of the charges with the secondary company along with a copy of the Explanation of Benefits (EOB) from the primary company. The secondary company usually picks up the remainder of the bill.

Participating provider

A participating provider is a medical provider who has signed a contract with a health insurance company or health insurance network to charge pre-determined rates to patients who are in the network.

Nonparticipating provider

A nonparticipating provider is a medical provider who does not have a contract with a particular health insurance company or network. If you use a nonparticipating provider, you will generally pay a larger portion of the bill. In some cases, you may be responsible for the entire bill.

Limited benefit plans

These are not considered to be comprehensive medical insurance plans. Instead, they provide very specific, limited benefits for different types of services. For example, they may provide a flat rate for each day you stay in the hospital or pay a limited amount for each surgical procedure that you have.

Typically, they are marketed toward people who cannot afford or are unable to obtain more comprehensive coverage due to pre-existing health conditions. Or, they may be geared toward people who have high-deductible plans. The good thing about these plans is that they generally pay in addition to any other coverage you may have. Therefore, no coordination of benefits is required.

If this is your only coverage, be aware that you will usually have to pay a large portion of any bill as these limited plans do not usually pay large amounts per day. For example, it may actually cost you $1000 a day to stay in the hospital. If your limited benefit plan pays you $200 a day for each day you spend in the hospital, you will be personally responsible for the remaining $800 per day.

Medicare supplement plans

People who have Medicare often choose to purchase a Medicare supplement plan as Medicare does not usually cover medical charges in full. Medicare continues to change and add new options but, in general, a supplemental plan pays the balance of the medical charges after Medicare pays its portion. For example, most Medicare supplements will pick up the Medicare deductible.

Some policies also pay for some of the charges that Medicare may not cover. There are many different policy variations. If you are not sure what you are purchasing, consider contacting a broker that assists senior citizens.

Health Insurance Facts to Know

How can health insurance help you out? Being an investment, it is imperative that people prioritize this expense along with many other financial responsibilities. Health insurance coverage should be there to support you and your family in times when you need immediate health care. Think of it as a nest egg where you can get funds from to pay for the various costs of medical treatment, hospitalization, medication, and more.

There are various types of health insurance plans that you can obtain, and there is an equally innumerable number of firms that offer such services. It can be a little challenging to choose one that is right for your budget, as well as tailor made to suit your health needs. Note that you don’t have to spend a fortune to be able to get insurance coverage. There are ways by which you can earn discounts and save, while at the same time receiving quality and reliable services from your insurance provider. All it takes is the right knowledge to be able to evaluate your health insurance priorities and lock down your choice of provider.

In line with this, this article presents some interesting statistics that you might want to keep in mind regarding health insurance plans in the United States. Knowing these important notes will help you make a wise decision with regards to choosing a plan for you and your family. Mentioned here is also vital news regarding the direction that the health insurance system in the US is headed.

How many people in the United States are without health insurance? Regardless of how important it is to be covered, there is a significant percentage of the population who has no resources to obtain their needed health policies. As the Centers for Disease Control and Prevention (CDC) reports, about 45 million people in the US have no health insurance. And that translates to roughly 15 percent of the population. The Hispanics have the most number of uninsured children and adults, which is about 32 percent of the total Hispanic population. On the other hand, 19 percent of the total African American population does not have health insurance, and around 10 percent of all whites are uninsured as well.

If you are interested to know, there are specific states that contribute the most to the uninsured adult statistics in the country. If nearly 20 percent of Americans aged 19 to 64 have no form of health insurance, which states significantly add to that number? To be more precise, Texas and New Mexico have almost a third of the total aged 19 to 64 population uninsured. On the other end of the spectrum, Massachusetts has the least number of uninsured adults in that age group, with only about 10 percent accounted by the Kaiser Health Foundation statistics.

How many children in the US are without any form of health insurance? This age group is considered as the minor group, comprised of children aged 18 and below. The CDC stated in a 2007 report that about 10 percent of the total minor population does not have health insurance. That means that there are 7 million children out there who may not be able to get afforded medical treatment. Which states have the most number of uninsured children? The Kaiser Health Foundation accounts that Texas ranks at the top of the list, with about 22 percent of the ages 0 to 18 population having no health insurance. Massachusetts is still the state with the least number of uninsured children, with only about 5 percent having no coverage.

In terms of the performance of insurance companies in the country, which are the ones that write the most number of health policies? As of the year 2007, the National Association of Insurance Commissioners reports ten of the largest insurance firms in the US, with respect to their market shares. Topping that list with approximately 12 percent of the market share is the UnitedHealth Group. Second is WellPoint, Inc, having almost 10 percent of the market share. The third largest with 7.7 percent market share is the Kaiser Family Foundation. Blue Cross, which is among the oldest health insurance providers in the country, ranks ninth, with a market share of 1.7 percent.

On a final note, what does the American government intend to do in response to the ever growing health insurance needs of the country? Among the highest priorities of the new Obama administration is to focus on revamping and further developing the health insurance system in the US. About $150 billion is expected to be allotted for provision of more accessible and more affordable health insurance options for the population. In line with the recession which led to the loss of over 7 million jobs, $25 billion will be used to cover for nearly 65 percent of health insurance premiums for these employees.

To be able to answer to the health needs of children, it is expected that 5 million kids will be granted health insurance, as $87 billion will be for funding state health insurance programs, including the SCHIP or State Children’s Health Insurance, which assists minors from low income families as well. The rest of the funding will be for modernization of medical facilities, including access to records, as well as research for diseases such as cancer, Alzheimer’s, diabetes, and heart conditions.

How to Get Cheap Health Insurance

Cheap health insurance may look like a bargain, but what happens if you have a major medical problem? You don’t want to be caught off-guard if an unexpected major medical problem arises. Cheap health insurance means one thing to one person and something else to another. While the idea of getting cheap health insurance is very appealing, no one wants to deal with the repercussions of bad or inadequate health insurance. Cheap health insurance has become the issue of the moment in South Carolina and across the country. More small businesses are increasingly unable to provide cheap health insurance plans to their employees because of the rising cost and the lack of federal and state legislation that would allow small businesses to purchase cheap medical insurance in pools.

Cheap health insurance is your access to the best options in the market. This is because you no longer have to spend so much time searching for the product that will suit your health care needs. Cheap health insurance rates work so much better when you know what you are supposed to be looking for. Get some tips on what you should look for when dealing with a health insurance plan. Cheap health insurance quotes can help you to find the best and the most inexpensive coverage that is available. You will be covered, and relieved to know that if anything happened to you, you will not have that major financial stress of paying full price for your injuries or illnesses.

Medicare supplemental insurance offers senior coverage for health care costs that are not covered by a traditional Medicare plan. By having Medicare supplemental insurance, seniors can rely on consistent, constant and comprehensive coverage when they need it. Medicare supplemental insurance is designed for people on Medicare, who wish to have more comprehensive coverage. These supplemental plans may include Managed Care HMO plans or Medigap PPO plans that provide you with greater access to participating physicians. Medicare and Medicaid are both excellent programs for those individuals who qualify, but they are no substitute for a system which allows us all to access basic private medical insurance cover at a cost which we can afford.

Medical Insurance also known as health insurance is a protection to individuals and their families against unforeseen expenses. In the process, there are two parties namely the insurer and the insured. Medicaid is for people who come under the low income’s bracket. Every person is eligible for it and having a job does not affect one’s eligibility. Medical terms can be confusing, and before speaking with an insurance agent, you should make sure you understated his or her language. Make sure you read our overview of health insurance companies to get a better idea of each provider’s identity.

Individual companies are free to evaluate the risks to insure you in whatever manner they see fit. Each health insurance company employs people (actuaries) that try to calculate the statistical risks involved in insuring you, and not surprisingly, has a slightly different view of the statistics. Individual health insurance works differently. It generally can’t be terminated just because you use it, but you can be turned down in the first place if you do not pass health underwriting; you can be rated up if you have a history of illness or obesity; and your premiums can be and often are increased if you suddenly have a major illness. Individual health insurance covers different types of injuries as well. An active lifestyle increases the risk of accidental injuries and repairing broken bones can become very expensive.

Individual health insurance is State specific. Each state has slightly different laws and regulations governing the implementation of private individual health insurance.

Hospitalization, medicines, doctor fees can be very high and if the patient cannot get a suitable insurance cover, it is very difficult. Health insurance can be a tough battle for cancer patients. Hospitals have an extraordinary ability to save life and without health insurance you could be medically saved but financially ruined. Hospital cash plans are a form of medical insurance that takes care of everyday medical costs. Many will pay for dental or optical treatment up to a set limit every year; physiotherapy; specialist consultations etc.

Comparison of your options: To be able to find an affordable health insurance you must have an idea of all. What is available in the market? After you have shopped enough get hold of a broker who can help you in comparing the policies. Comparing health insurance is a case of finding the right health insurance provider to cover your particular circumstances as well as comparing the types of policy provided by each health insurer.

Comparing Medical Insurance isn’t just a case of finding a handful of brand names and trusting they have everything covered in their policies. The cover varies wildly, as will your medical insurance quotes. Compare several plans from top rated medical insurance companies and apply online.

COBRA, short of Consolidated Omnibus Budget Reconciliation Act, came into being in 1985, and it is also a low cost health insurance option for short-term coverage up to 18 months. It’s great for transition periods such as school age children, widowed spouses, divorced couples, and other situations where you may have been covered by employee programs previously. COBRA has an 18 month limit, or 36 months if you’re permanently disabled. Most people are under the impression that COBRA is expensive, or that it’s better to stay with a plan they know.

Again, depending on where you live, requirements may be stringent. However, it wouldn’t hurt to see if you or your family qualifies. Ask around to find out about the different agents and their policies. Many agents will work very hard to get you an affordable health insurance plan for your family at a cost you can live with. Ask if the agent will be available for phone calls and if he or she will make phone calls on your behalf if you have questions in the future. Ask your agent to be sure.

Ask for a quote from several sources, and see what kind of a deal, they can get for you. Make sure they are also licensed in your state, because it does no good getting insurance if they can’t operate in your state. Ask about policy rates, terms, services, co-pays, and claim procedures. If the representative has a difficult time answering your questions, or you just don’t think the company is legit, consider visiting your state’s Department of Insurance website to read through reviews and financial information of the company.

Thank you for taking your time to read this article. Your comments on this article will be highly appreciated. To access Hundred of Gurmit’s articles, please visit websites.

Information shared here does not constitute financial, legal, or other professional advice, and no advisor-client or confidential relationship is or should be formed by use of the site. This article is intended to provide general information only and does not give advice, which relates to your specific individual circumstances. Information in this document is subject to change without notice. Any link-listing or ad-listing on this site does not constitute any type of endorsement.

Before Choosing Health Insurance

Understanding Health Insurance

This article is written to assist consumers sift through multiple options, plans, exclusions and summaries of benefits and understand what Critical questions you should ask when researching health coverage. Finding the most beneficial health insurance plan to meet your unique and individual needs is difficult. This guide will help consumers understand the basics of health insurance and what to look for when comparing plans.

14 Costy Mistakes You’ll Want To Avoid

1-FREE – Do You Have a “30 Day FREE Look Period?” Can you get your $ back if you are not happy?

2- DEDUCTIBLES: How many deductibles do I have per year? Some plans will have more than 1 deductible per person per year!

3- NETWORK RATES: Prior to your deductible being met, will your insurance company extend their discounted network rates to you? Example: Insurance Company A – 5 stitches to finger – Total cost $2000, patient responsibility, $800, or Insurance Company B – 5 stitches to finger – Total cost $2000, patient responsibility, $2000. (no network break).

4- NEGOTIATED RATE: What is the AVERAGE negotiated rate? (Sometimes referred to Network Rate – very very important!)

5- UNCLEAR TERMS Is your $100 “co-pay” for an Emergency Room visit REALLY $100? Some companies the $100 copay is more like a fee AFTER your deductible, and you’ll still pay the co-insurance and the $100.

6- LIMITS on benefits, for example: $500 limit or $250 limit on Emergency Room expenses. $50 limit on Dr. Visits. Once the Limit is reached, YOU pay everything else out of pocket. $500 limit on hospital expenses per day (quick way to bankruptcy!)

7- PREVENTATIVE – Will you have to meet your deductible, or do you have a 1 year waiting period for preventative? Do you want to wait 1 year before you can have your female exam, or a mammogram?

8- TRAVEL – If you are out of state, are you covered for illnesses? If you eat something that doesn’t agree with you and become very sick and need a doctor, will you be covered? (Not just life threatening emergencies.)

9- RATE INCREASES – I am buying a “fixed rate”. Ask yourself if it makes sense to pay extra over the next 2 – 3 years for a fixed rate? Make sure your rate is set for at least 12 months but does it make sense to pay in advance for a fixed rate? Sometimes plans will naturally go down in price, so does it make sense to pay extra to have a fixed rate?

10- SUPPORT – After I buy this plan, MAY I CALL MY AGENT’S DIRECT LINE with billing issues, or plan questions, or technical problems, or claims questions or concerns of any kind?

11- EXCLUSIONS – Read the “Exclusions” in your plan. Are the exclusions available for you to read? Is there an exclusion that you cannot live with? For example: exclude well baby visits. Is this an exclusion that you didn’t catch in the plan details?

12- MAJOR MEDICAL plans are designed to pay for MOST of your medical expenses when you become ill or injured. You’ll want a Major Medical plan from a reputable company that has “Credible Coverage.” Discount plans or Limited Medical Plans are NOT designed to protect your losses like Major Medical plans are. They are marketed as “Insurance,” but you MUST ask, is it a Credible Coverage Major Medical plan?

13 – MATERNITY – Maternity plans. Do your homework. Does your plan have an outrageous deductible for maternity? Do you have a waiting period of 12 months, 24 months, or more? How many doctors do you get to choose from “In Network” that can deliver your baby? Are you happy with the choices of Doctors in the network that will deliver your baby? What if your doctor is not on-call the night you go in for delivery?

14- MEDICATIONS – Is there a limit on how much the insurance company will pay for medications. If you become very ill, this could be a very big problem. Do your research, ask questions. Do you have a deductible on medications?

*Did you know that key information about how coverage works is not always disclosed? *When comparing plans, is the language confusing? Why is the language confusing? *Did you know that many consumers compare prices of health insurance plans, but cannot always tell if they are comparing “apples to apples.”

How to avoid Medical Bankruptcy!

According to a Harvard Law and Harvard Medical School study, they found that ½ of all bankruptcies are caused by illnesses and medical expenses. If you are a breadwinner for yourself, or breadwinner for a family or spouse, and the breadwinner gets sick, you may loose your medical coverage, and a way to pay for your day to day expenses.

When you are shopping for a health plan to protect yourself financially from medical bills and bankruptcy, there are many things to consider. Probably the most important thing is to consider is what “Type” of plan you are getting. There are several types of health plans that are available. If you buy a plan that is not “Underwritten” and is “Guaranteed Issue” you are not buying a Major Medical Plan. Major Medical plans will go through a process called “underwriting.”

Some plans will pay a certain dollar amount for a procedure, or a certain dollar amount per day while in the hospital. IT IS CRITICAL you understand the implications financially if choosing a non Major Medical plan. Your chance for greater personal losses including Bankruptcy exist with non-Major Medical plans. If you are shopping price with health insurance, and you decide on a discount or limited liability plan, YOU HAD BETTER UNDERSTAND WHAT YOUR RISKS ARE if you end up needing to use that “insurance.”