Entries Tagged 'Health Insurance' ↓

When dealing with a health insurance plan, whether a new one or the one you have already purchased, the specific language of its contents can be confusing for most people. All these provisions, coverage options and payments make little sense unless you are an insurance expert. And it’s not that rare that a person asks what does their policy provide even after having it for some time.

Don’t worry, we are here to help you. Below you will find the most commonly used health insurance terms you will find in any policy with brief and comprehensive explanation that will help you understand your insurance policy better.

Deductible

Deductible is the sum of money the policy-holder has to pay out of pocket before the policy benefits will kick in. This amount is typically set on an early basis, meaning that a certain part or the whole deductible in the current year, this amount will be renewed in the next one. Certain services provided by the insurance policies such as physician visits are available free of deductible. If you have your family members included into your policy, there’s usually a separate distinction between individual and group deductible amounts.

Co-insurance (Co-payments)

The sum of money you have to pay on your own before your policy starts covering you in addition to the plan’s deductible. Certain plans will require only co-insurance payments for some types of services without requiring you to pay the deductible.

Out-of-Pocket

It’s a general term denoting all payments that you have to make on your account before the policy coverage kicks in. This usually refers to deductibles, co-payments and co-insurance. When speaking of annual out-of-pocket maximum this term refers to the overall costs of the insurance policy during the year minus the premiums. Continue reading →

One of the more annoying features of modern life is this alphabet soup. You are expected to know what all these letters stand for, iykwim. Even those who are into texting and SMSing can get caught out when it comes to insurance jargon. So here is a simple explanation of the differences between a Health Maintenance Organization (HMO) and a Preferred Provider Organization (PPO) with guidelines to suggest which to buy. Both employers and the private health insurers offer this choice. An HMO is a network of healthcare providers that enters into a contract with insurance companies to provide medical services at a fixed price. This network will include hospitals, clinics and a range of professionals. Usually they are grouped together in a particular part of a city or rural area, offering a spread of coverage across the major medical specialties to all the people living within that area. Because the insurers can bring a guaranteed volume of business to the network, they are able to negotiate quite good prices for the different services. These savings are passed on to you as lower premiums. Even more importantly, service within the network can be free or with only low copayments. But the majority of plans have quite restrictive terms. When you sign up, you have to choose one doctor to be your primary care physician. This person must be an existing member of the network. If your current doctor is not a member, you will have to change. This physician acts as the gatekeeper and he or she must refer you on to specialists within the network. Because the insurers pay bottom dollar, the gatekeepers tend not to refer on unless the problem is really serious. Further, because the network is for-profit, it must see more patients in a day to earn a reasonable profit. You may therefore expect little opportunity to discuss your treatment or explore options. You have only a few minutes and must make the most of that limited opportunity.

PPOs also negotiate contracts with the insurers but the organization of the network tends to be loose. Unlike an HMO, the PPO does not limit you to a single physician. You can see anyone within the network at the standard price. If you go outside the network for specialty advice, you will have to make out-of-pocket payments. So, this gives you more control over the medical care you buy but, as a result, costs more. Continue reading →

There is something deeply annoying when people in a particular trade or industry start using jargon and letters to talk to us. What is wrong with the English language? Why must they hide the meaning? Why do they believe we will be impressed? The insurance industry is one of the worst offenders. By the time the experts have finished describing the different health plans and the lawyers have wrapped everything in obscurity, we seem left with a take-it-or-leave it choice. They seem to be saying, “close your eyes, trust everyone has your interests to heart, and pick something out of the alphabet soup.” Well here is a quick tour through two of the most common plans to help you decide.

The essence of all plans is a definition of the healthcare professionals available to deliver the care should you need it. The wider the choice you have, the higher the premiums you will be required to pay. With a Health Maintenance Organization (HMO), a group of healthcare providers contracts with an insurance company to deliver services to the policy holders. Because the insurance company guarantees a high volume of business to the group, the rate for the services is lower than usual and so the premium rates charged and copayments are also lower. Access to the services is controlled by a primary care physician. He or she will refer you on to other members of the group for different specialist services. If you want to go outside the group, you will have to pay the difference between the HMO rate and the actual cost of your own choice doctor. Although this is the cheapest form of plan, the lowness of the fees charged by the group encourages members to see as many patients as possible every day.

A Preferred Provider Organization (PPO) also contracts with an insurance company, but the relationship is less restrictive and the rates are slightly higher. In this plan, you are free to choose any doctor within the group without having to get a referral. If you decide to see someone outside the group, you will have to pay the out-of-pocket expenses. Here, you are paying slightly more to have more control over your treatment options. So, for example, if your own doctor is not a member of an HMO, you would have to change. With a PPO, you can continue to see your own doctor. Continue reading →