Frequently Asked Questions for Health Insurance

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This year, if you have been uninsured for 6 months and have a pre-existing condition, you will gain access to health insurance that was not previously available to you.
A new program – known as a high-risk pool – will provide affordable insurance for Americans who are uninsured and have a pre-existing condition. This program will provide temporary protection for people with pre-existing conditions until 2014, when insurance companies can no longer deny you coverage based on your health.

A physician chosen by the enrollee that is contacted in case of any medical issues. This doctor manages any other care that a patient might need, like hospitalization or specialist visits. This physician is commonly referred to as your general practitioner or family doctor.

If you have an HMO plan, you usually need to get a referral to see a specialist. Some HMO plans allow you to go directly to some types of specialists. With POS plans, you usually need a referral if you want to use the HMO feature of the plan. If you use the PPO feature of the POS plan, you can self-refer. With PPO and major medical plans, you can go directly to specialists.

In terms of quality, choose a doctor who is board-certified, who has attended a reputable medical school, is experienced and has admitting privileges at a JCAHO accredited hospital. You should also select someone with whom you feel comfortable.

Also consider how busy the physician is and the quality of the office staff. You don’t want to wait weeks for an appointment, interact with a doctor who doesn’t have time to answer your questions or deal with rude office staff.

That depends on the plan. If you’re dealing with major medical plans, there are no restrictions on doctor choice. If you’re involved with managed care plans, you’ll want to see if your doctor is in the network before changing plans.

Managed care companies organize providers into contracted networks. Network providers agree to deliver care at discounted rates in exchange for an increased volume of patients. Although managed care plans give you the option of using out-of-network providers, you will have to pay more for their services. First, the percentage your insurance company pays will be less. Second, the fees of out-of-network providers are usually higher because they haven’t agreed to discount their rates for your health plan.

Most health plans require that you obtain a second opinion prior to undergoing a surgical procedure and will provide coverage for it. If you’ve been diagnosed with a serious illness, it’s a good idea to get a second opinion, even if you have to pay for it yourself. An experienced doctor can make a difference—both in correct diagnosis and successful treatment.

Local community hospitals tend to be smaller and more personal than teaching hospitals. For minor or routine surgeries, they’re probably fine. However, if you have a serious condition and want the best experts, choose a teaching hospital. Teaching hospitals are training sites for medical specialists and the places where leading-edge research is conducted.

Whatever hospital you select, make sure its received a good accreditation rating from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Call the hospital’s patient relations department to obtain that information or visit the JCAHO Web site: www.JCAHO.org.

Copayment is a specified amount that you pay for a service or product, such as $10 for an office visit, $12 for a prescription, etc. Payment is usually required at the time you receive the service or product is received.

Coinsurance is a percentage of the total cost of the service received. Plans identified as 80-20 refer to such cost-sharing arrangements (80 percent of fee paid by the plan, 20 percent paid by you). Both copayments and coinsurance are out-of-pocket costs.

Balance billing is a provider practice of billing for expenses either not covered or partially covered by your health plan. For example, if some of the services provided during your doctor’s visit aren’t covered by your plan, the doctor will bill you directly for those services. Balance billing may also occur when the provider’s fees are higher than the health insurance company considers usual and customary for a particular service. In this case, you may be responsible for paying the balance, unless the agreement between your plan and the provider prohibits balance billing.

The out-of-pocket maximum fixes the annual dollar amount you must pay before the insurance company pays all remaining covered expenses at 100 percent. In comparing plans, the one with the lowest out-of-pocket maximum dollar amount—say $1,000 versus $2,000—is most likely the plan with the highest level of coverage. The out-of-pocket maximum is an important consideration if you anticipate using a lot of services.

Each state decides independently what types of benefits insurance companies in that state must provide. Since requirements vary from state to state, you need to obtain that information from your state’s health insurance regulating agency.

According to the Emergency Medical Treatment and Labor Act (EMTALA), an emergency medical condition is one in which acute symptoms are so severe (including severe pain) that the lack of immediate medical attention could result in serious damage to bodily functions or organs, or placing the health of an individual or unborn child in serious jeopardy.

For a pregnant woman who’s having contractions, an emergency medical condition includes insufficient time to safely transfer to another hospital before delivery or a transfer that may pose a threat to the health or safety of the woman or her unborn child.

With a major medical plan, you’ll have coverage with any doctor anywhere. Most managed care plans cover out-of-area services for emergency care only, although some also include urgent care.

Coverage of preexisting conditions varies from plan to plan. Most exclude coverage for a certain amount of time for conditions diagnosed or treated prior to your signing on with a new plan. Read the plan’s coverage description carefully.

In most cases, if your husband works for a company with more than 20 employees, you and your children will be eligible to continue his employer’s health insurance benefits under COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) for up to 36 months. Your other options are to obtain coverage through your employer or shop for an individual plan to cover you and your children.

Your insurance company cannot cancel your insurance simply because you use it a lot. It can be cancelled, however, if you don’t pay your premiums, you move out of the service area, you don’t follow managed care plan rules or you leave your employer.

Your health plan is primary. That means your employer’s plan covers you for services you receive that are part of the plan’s schedule of benefits. Your coverage under your husband’s plan is secondary. This coverage can be useful when you want payment for a service that’s not included in your plan. For example, if maternity benefits were included in your husband’s plan but not in yours, you would be able to get your maternity care paid for by your husband’s (secondary) plan. The premium cost for you as a dependent on your husband’s plan needs to be weighed against the dollar value of the extra benefits you would receive.

Acupuncture, chiropractic, and massage therapy are the treatments most commonly included in a health plan’s alternative medicine coverage. Some plans offer discounts on nutritional supplements and selected alternative services.

If your employer provided health insurance and the company has more than 20 employees, you’re probably eligible to continue your employer’s health insurance benefits under COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) for up to 18 months. You’ll be responsible for paying the entire premium yourself plus an administrative fee (up to 2 percent). Ask your benefits or human resources personnel about COBRA. If you know that you’ll be covered by a new employer’s plan in a short time, you may want to consider a short-term medical plan instead of COBRA.

Although a good health insurance plan will take care of your medical expenses, it doesn’t provide financial resources for maintaining your business. That’s why many people purchase disability insurance. It replaces a portion of the income you lose when you’re unable to work due to a long-term illness or a serious injury.

Short term health insurance policies are typically offered in increments of 3, 6 and 12 months. Any coverage desired for longer periods should be covered by a personal or long-term health insurance policy. Short-term coverage is less comprehensive than a long-term policy; the short-term policy typically covers the insured against unforeseen incidents or illnesses and is not designed to address his/her overall healthcare insurance needs.

One way health insurers control costs is to require a higher co-payment for brand-name drugs than for their generic equivalents. In some cases, an insurer may refuse to cover certain brand-name drugs altogether and offer coverage only for the generic equivalents.

In the vast majority of cases, the generic equivalent is a suitable (and less expensive) substitute for the brand-name medication. If your doctor feels that your condition requires the brand-name drug, but the drug is not covered under your prescription plan, ask your doctor to petition the insurer for coverage due to medical necessity. Your insurer may cover the brand-name drug after your doctor provides the facts of your case.

There are currently no federal laws requiring companies to provide their employees with health insurance in 2011. However, there are a handful of states that do require employers to offer some form of health coverage to the employee. In most cases the employer is not required to offer health insurance to the employee, let alone the partner of the employee.