about health plans today
what should I look for in a healthplan?
how do plans work? what makes up a plan? what's a network?
what should I look for in a healthplan?
Being IN a plan that provides a network of doctors and hospitals is THE single most important factor in buying healthcare. All plans have separate co-pays and co-insurances for 'out-of-network' expenses. This is due to out-of-network doctors and hospitals being able to charge whatever they want. In turn, insurance companies pay more and the member pays a larger percentage of a higher bill. It is important to know WHO and WHAT is under your network umbrella!
Co-pays and the percentage of co-insurance is another. If you have high blood pressure and see a doctor several times a year, a doctor office co-pay is important. If you're on daily medications, RX co-pays are important. If you decide to go with a high deductible plan, you might want a 100% co-insurance plan so you know exactly what is coming out of your pocket.
whats a network?
POS, PPO, Traditional and HSA Plans
All of the plan types below work within a
carrier’s network. In
some cases, a carrier might have a different network for a
different series of plans. Be
a smart consumer and ask. It
never hurts to ask.
PPOs (Preferred Provider Organizations) are today’s most
popular plans. The Provider
Organization is the network of Hospitals and Doctors
the carrier has negotiated with for Plan (or Series of Plans)
coverage (or benefits). This
means the insurance carrier and the (hospital) network have sat
down and negotiated costs/charges for just about everything a
member might require so the carrier knows what each service will
cost (when and if used).
POS (Point of Service) plans are the ‘primary care physician’ (PCP) plans. These require the member to name a physician to work through. See this physician who, if necessary, refers you to a 'specialist.' Sometimes these plans are 'Three-Tiered.' Meaning, the lowest rates (at costs to members) are provided at the PCP level. One step costlier at a 'specialist' (in network) level; and, of course, the highest or most expensive level is the 'out-of-network' costs.
PPO and POS plans most often provide an office and Rx co-pay
right from the get go (you don't have to meet the deductible
first). In addition,
there is a deductible that needs to be met should something major
or catastrophic happen. Meet
the deductible, then plan pays a certain percentage of all costs
until the ‘out of pocket maximum’ is met – then the plan
pays 100% of expenses.
Tax-Free Savings Accounts
HSAs!
These are the governmentally controlled, tax-advantaged
plans everyone’s talking about. Simply, an HSA has two parts:
1) a major medical plan with a High deductible, and 2) a
savings plan.
Some carriers combine the two into one premium (investing
the ‘savings’ portion and giving you a ‘rate-of-return’
for the year), while others use a banking service that is applied
for separately. The
member, in a lot of cases, then gets to select their own
investments; hence, they control the rate of return.
There are a lot of advantages for using this type of plan.
Obviously, saving is a good thing especially when its earmarked
for medical expenses. These dollars can come out of
'savings' annually without increasing your income - hence, income
tax - IF they're used for medical expenses. That's where the one part of the tax-free dollar
reference comes from. The other is dollars going into
savings are also tax-free. If you hate throwing more money
at Uncle Sam, this is something to look at hard. All or most
carriers are now offering them to the general public.
Plan
Pieces and Parts in general consist of a (major medical) deductible, Out
of Pocket Maximum ($), Lifetime Maximum, Office Co-Pays, Rx Co-Pays,
Emergency and Urgent Care Co-Pays.
However, some plans also have separate office co-pay deductions
and Rx co-pay deductions, further some have annual dollar limits on
benefits. New, to the market are ‘limits’ in the number of office
visits you can have on an annual basis.
This makes sense AND can save you money.
What you look for depends on your needs.
If you have high blood pressure, you are going to need a plan
with office co-pays to be monitored.
If you have no health issues, go with a plan that pays 100% after
you meet the deductible. This
will protect YOU along with your assets.
A simply six hours in an emergency room could easily cost $5,000.
You can’t afford NOT to have at least some sort of catastrophic
coverage. Most carriers
offer these type of plans.
In a PPO or POS plan any time you see the phrase Co-Pay with a $
this indicates a dollar amount the member pays for the service described
beginning with the effective date of the policy.
Unless otherwise noted, you don’t have to meet a deductible to
use this benefit. Co-pays
are not usually applied against the deductible.
Any
out-of-pocket monies beyond the dollar co-pays are applied to the
deductible. Should
something happen and the Plan deductible is met, then the plan pays
bills for services at the percentage rate (%).
Usually 80% or 100%. On
plans other than 100%, there is another limit.
The total out-of-pocket limit (for a given plan year) of the
percentage you are responsible for paying.
(Careful here again - Some plans specify the deductible per
'incident.' This means you could possibly have more than one
deductible to meet.) (Highway robbery) it could be another
$1,000 or several thousand dollars – at which point the plan then pays
100% of expenses incurred for the covered services.