Health Insurance 101
Health insurance covers the costs associated with illness and injury. It also covers the cost of preventing illness, such as annual physical exams and vaccinations. Health insurance can include vision insurance.
The following discussion is a basic health insurance overview. For information about the subjects discussed, see the links at the end of this article.
Types Of Health Insurance Policies
- The federal government provides health insurance under programs such as Medicare (basically for the elderly and people who have been disabled for 29 months) and Medicaid (for people with limited income and assets).
- Private coverage offered by private insurance companies.
- Fee-for-service (Indemnity), Managed care (HMO), Combinations
- The earliest standard health insurance pjolicies were Fee-For-Service (indemnity) type policies. In a Fee-For-Service policy, the insured has free choice about which health care services to use. The insured pays the bill and is reimbursed by the insurance company.
- At the other extreme are HMO and other managed care type policies. In these types of policies, care is managed by the insurance company. Consumer choice is limited.
- In between these types are policies which combine features of both. For example, POS (Point Of Service) and PPO (Preferred Provider Organization) plans.
- High-Deductible Plans (also known as Consumer Directed Plans) combine one of the above plans with a high deductible so that the insured pays a considerable amount of money per year before the insurance takes over and generally with a tax advantaged savings account.
Exclusion of Coverage For Pre-Existing Health Conditions
A waiting period for health insurance purposes is a period of time during which a health insurance policy excludes coverage for an existing health condition. A waiting period is also known as a "pre-existing condition waiting period."
If this kind of period applies to you, there will not be any coverage for your existing health condition until the period expires.
The Health Insurance Portability and Accountability Act of 1996, generally referred to as "HIPAA," places limitations with respect to what can be considered to be a pre-existing condition and how long it can be excluded.
If you are starting group coverage with an employer and you have had other health insurance coverage recently, you may avoid a new Pre-Existing Condition Waiting Period because of the time you spent under prior insurance.
As of January 1, 2014, because of the Affordable Care Act ("Obamacare"), there are no longer waiting periods with respect to health insurance in individual policies.
Which Type Of Policy Is Best For You?
There are no studies which indicate whether a particular type of policy is better for a person with a particular health condition. Studies do show that people with a chronic or serious health condition can receive as good care under a managed care plan as under a Fee-For-Service plan.
There are advantages and disadvantages to each type of policy.
If you have a choice of health insurance plans, there are many factors to consider to determine the best plan for you (and your family). If, when you consider them, it is not clear which policy is best, we have a Health Plan Evaluator to help make a reasoned decision from the point of view of a person with your health condition and your individual needs.
Also consider speaking with a financial planner or an insurance broker who has experience with people with a serious health condition.
How To Maximize Use Of A Health Insurance Policy
- To be a wise health care consumer and to maximize use of a health insurance policy, it is useful to understand the concept behind the policy, as well as the terms generally used.
- If an insurer refuses to allow you to obtain a service you need, or refuses to pay a claim, every insurance policy has a feature built in allowing you to appeal the decision on an internal basis. studies show that the majority of appeals turn a "no" into a "yes." According to the experts, the key is to be persistent. If all else fails, you can complain to the insurance regulators in your state - and ultimately access the court system.
How To Get The Health Care You Need
To get the health care you need, it is advisable to learn how your policy works, and then follow the terms of your policy. For instance, HMO type policies require pre-certification (approval of the expense before you receive care or treatment) or it may only involve sending a bill to the correct location in a timely manner.
If an insurer refuses to allow you to obtain a service you need, ask to speak with a case manager. He or she may be able to help, or to suggest workable alternatives. If the insurer continues to refuse to allow you to obtain a service you need, or refuses to pay a claim, appeal. It is not difficult to appeal, but you must do it within the time period specified by the insurer. Most appeals turn a "no" into a "yes." According to the experts, the key is to be persistent.
You may have the right to appeal to an external decision maker after exhausting the insurer's internal appeals.
You can also complain to the state regulator. Ultimately you can access the court system to get the care you need.
Financial assistance is available if you need help paying for health insurance premiums or other costs relating to your health insurance. For information, click here.
Links To Information
- GOVERNMENT INSURANCE
- TYPES OF HEALTH INSURANCE AND HOW TO MAXIMIZE USE OF EACH TYPE OF POLICY
- Types of Health Insurance Plans
- Health Insurance: POS
- Health Insurance: Out Of Network
- Health Insurance: PPO
- Health Insurance: HMOs
- High-Deductible Health Insurance
- Pre-Existing Conditions Limitations
- How To Get Your Insurer To Pay For The Costs Of A Clinical Trial
- Experimental Treatment
- HOW TO CHOOSE A HEALTH INSURANCE POLICY
- IF A HEALTH INSURANCE COMPANY SAYS "NO"
- OTHER HEALTH RELATED INSURANCE
- For information about steps to consider If the costs associated with your health care result in a financial crunch or crisis, click here.
- In addition to health insurance, other insurance products which cover health are Hospital Indemnity Insurance, Accidental Death and Dismemberment Insurance and Cancer and other specific illness policies. Long term health care is provided by Long Term Care policies. For information about these policies, see the documents in "To Learn More"
- Until you obtain health insurance, there are steps you can take to help minimize the cost of using the health care system. Steps include obtaining a medical discount card and/or short term health insurance for a limited period of time. Free or low cost medical care is also available. For more information, click here.