Health Insurance Articles

It is very important if you have health insurance provided by your employer that you understand what your rights are under COBRA (Consolidated Omnibus Budget Reconciliation Act).  This important legislative act guarantees that workers participating in their employer’s health insurance program, as well as their dependents, have the ability to have their health insurance coverage extended after they leave their place of employment under specific circumstances and for specified periods of time.

Before COBRA was passed, as soon as an individual was not employed access to his or her group health benefits were immediately stopped.  Individuals with pre-existing conditions often could not obtain new insurance coverage.  Under COBRA, individuals can elect to continue participating, at their expense, in the employer’s group health plan after qualifying events that lead up to them leaving their employment are met.  It can expensive to do this, but it is better than becoming uninsured and all the consequences that follow.

If you quit your job voluntarily, you can elect to continue your employer’s group health insurance coverage for a maximum of 18 months after leaving your employment.  You are also eligible if your employer terminates you unless you committed gross misconduct.  For employees whose work hours are cut which results in them losing eligibility for full-time benefits, they can also choose to continue their coverage under COBRA.

There are certain conditions where COBRA coverage may be available for more than 18 months.  If an individual becomes disabled and is unable to go back to work, they become eligible for 11 additional months of health insurance coverage under COBRA, making the total amount 29 months.  If an individual dies who has covered dependents, the dependents are eligible for up to 36 months of coverage, as well as dependents who lose their coverage due to a divorce.

It is important to keep in mind that former employers are not responsible for covering any expenses of health insurance coverage for former employees who are continuing their coverage under COBRA.  If you decide to go with COBRA coverage you will have to pay the entire cost of coverage to your former employer and may also be subject to an administrative fee.

If you elect COBRA coverage and then fail to make your premium payments, your former employer can stop your coverage.  Your must make your first premium payment within 45 days of when you elect the coverage.  Your subsequent premium payment due dates will vary depending on your particular plan.  There is a 30-day grace period, which is required under COBRA, for making premium payments.  After the grace period is over, your former employer can terminate your coverage.

Instead of having to obtain individual coverage or go without insurance, COBRA gives individuals the ability to continue their coverage for a temporary period of time after their eligibility for health benefits is over.  COBRA can be quite expensive, but it is better than having no health insurance coverage at all.

A Preferred Provider Organization (PPO) is a network that includes doctors and other types of health care providers along with hospitals that work with a health insurance company or some other kind of third-party administrative organization for the purpose of providing a managed health care plan.  The providers that belong to the network provide health care and medical services to individuals and families who purchase the insurance company’s health insurance plan at reduced rates compared to what individuals without the insurance pay.

PPO plans are similar to HMO plans in some respects.  They both cover the full costs of health care visits made to network doctors and administrators.  Where PPOs difference from HMOs is in the fact that the PPO also offer their policy holders some flexibility in terms of being able to select a primary care doctor.  Under PPO plans, policy holders can elect to not have a primary care doctor.  With PPO plans, you can also see specialists without getting a doctor referral.  With an HMO a doctor referral is required for specialist visits.

Another way in which PPO plans are different than HMO plans is that with PPO plans, policy holders can visit specialists and doctors who do not belong to the network.  However, for non-network visits policy holders will have to pay part of the expenses, as the insurance only covers a portion of the costs.

Another advantage that PPO plans have is that there network extends further, providing wider geographic coverage than most HMO networks.  Most HMOs do not provide out-of-state coverage, but many PPOs do provide this.

However there is a price to be paid for the increased flexibility.  PPO plans usually cost more than HMO plans.  PPO policy holders will usually end up paying higher insurance premiums as well as covering some of the costs that are incurred when visiting non-network health care providers.  These costs are usually co-pays and usually have to be paid to the non-network provider at the time of the visit.

A typical PPO plan will cover all or part of these costs:

• Network primary care doctor visits
• Network specialist visits
• Prescriptions
• Diagnostic lab tests
• Hospital procedures including essential surgery
• Emergency treatment
• Partial reimbursements for the costs of non-network providers
• Some plans offer dental services

Most PPO plans don’t coverage alternative therapies and treatments like aromatherapy, homeopathy and acupuncture.  Surgery that is elective, for example cosmetic surgery, is also not covered.

PPO plans are available for individuals, families and businesses.  HMO plans can usually only be obtained through employers, but families and individuals can obtain PPO health coverage without having an employer.

PPO plans are well suited for individuals and families who are looking for inexpensive health care but still want additional flexibility to what HMO plans provide.  Families and individuals who require care from specialists will find that a PPO is more beneficial than an HMO.  This is due to the fact that a PPO does allow policy holders to visit specialists without requiring a referral from a primary care doctor and they also pay part of the expenses of non-network visits.  PPO plans are also beneficial for people who frequently travel out of state due to the fact that PPOs do provide out of state coverage.

Cost for health care are always increasing.  It is practically unheard of to hear of a health care provider cutting their fees.  If you are looking for ways to save money on your heath care costs, hear are a few tips to help you out.

Prevention is less expensive than the cure
Living a healthy lifestyle is probably the best way you can keep your medical expenses down.  Eat healthy foods, exercise on a regular basis, and quit smoking.  These are three easy, or for you maybe not so easy, ways you can improve your health, increase your lifespan and cut your insurance costs.

Select the best health care plan for your situation
If you have young children or a large family you will want a health care plan that emphasizes preventative checkups.  You need to do some upfront research on what your options are in order to find the right plan for you.  There are several different types of health care plans for you to choose from.  They all have different deductibles, premiums, co-pays as well as other types of features.  Choosing the wrong plan could end up costing you extra money.  The right plan could end up saving you a lot.

Make sure you understand exactly how your insurance plan works
It is crucial that you understand just how your plan works in order to maximize your benefits.  Be sure that you find out whether or not you need to have a primary care doctor, whether or not you are able to self-refer outside of the network, as well as any other important factors.  Learn everything there is to know about your health care plan and be sure that you take advantage of all possible discounts.  For example, even if you do not have a prescription plan separate from your insurance, your health care plan may still offer discounts on certain items like alternative medicines or vitamins.

Go generic on your prescriptions
All insurance companies will charger you higher co-pays on name brand drugs.  Most companies have three or four tiers that they classify prescription drugs into.  Each tier will have a certain co-pay.  Every time you choose generic drugs you will save money.

Check your bills for errors before you file them
Before filing your bills make sure you check them over thoroughly for any errors.  Billing errors do happen and you may end up paying more than you need to.  Once you have checked the bills over, be sure to file them.  If you ever get into a dispute with the insurance company, these bills will be essential.

Another excellent reason for tracking your medical expenses is that some may end up being tax deductible.  Some tax deductible expenses include hearing aids and glasses.  However, you do need to keep in mind that the total of your medical expenses will need to be higher than a specified percentage of what your gross income is.

Join your partner or spouse’s plan
If you and your partner or spouse each have your own health care plan, you may want to find out if one is less expensive or in some way more advantageous.  If this is the case, you may want to join your spouse’s plan or your spouse join yours.

Watch for free services
Many clinics and hospitals provide free tests and screenings for things like blood pressure, cholesterol and blood sugar.  Be alert for what local medical clinics have to offer, particularly if your health insurance doesn’t cover certain things like preventative health care.

A Self-Directed Health Plan (SDHP) is a very flexible type of health insurance.  An SDHP combines parts of PPO plans and Health Saving Accounts.  It provides the user with the ability to choose whatever health care provider they want, whether they are inside or outside the managed care network.

An individual with a SDHP owns a savings account that contains funds intended to cover their health care costs.  However, the individual with the account is not required to make contributions, although they can if they want to.  The main contributor to the plan is the insurer.

The account is restocked every three months with approximately $500 for families or $250 for individuals.  This money can be used to pay for preventative health care that is covered under the plan.  Any money that is not used in the quarter can be rolled over to the next quarter, and any money that is not used in a year can be rolled over into the next year.

SDHPs focus much more on preventative health care than traditional types of managed health care plans. SDHPs have fairly low monthly premium costs, but have high deductibles.  However visits for preventative health care don’t require a co-pay or deductible.  Non-preventative visits require a co-pay and deductibles for non-preventative visits need to paid for the year in full before subsequent visits will be covered.  Unused deductible amounts do not roll over.

SDHPs also provide accessed to health care professionals through a preferred provider network.  Visits to network providers is optional and policy holders don’t need referrals to see specialists.  However visits to specialists and non-network doctors does require a co-payment.

Most SDHPs cover a wide range of preventative health care, including:

• Regular checkups, routine physical exams and consultations
• Pre-natal and post-natal care
• Immunizations
• Cervical screening and mammograms for women
• Screening and diagnostic tests like x-rays
• Home Visits
• Some plans include prescription coverage

Emergency health care and in-patience hospital care like surgery are not covered under the preventative section of the insurance plan.  For medical costs other than preventative health care, there will be a deductible that has to be paid before there is any insurance coverage.

SDHPs are well suited for families and individuals with low ongoing health care costs that include mostly preventative care costs like yearly check ups and routine physical exams.  People who enjoy good health can usually minimize their health care costs quite a bit with a SDHP.

One advantage to an SDHP is any unused funds can be carried over on a quarterly as well as yearly basis.  This means that unused funds can keep accumulating and then be available when expensive medical expenses come up.

For individuals with chronic health conditions like diabetes, a self directed health plan would not be suitable.  Chronic illnesses usually require frequent visits to the doctor as well as other medical care, and these types of visits and care are not considered preventative health care.

When it comes to managed care options, point of service (POS) plans can offer a lot of flexibility and a wide array of options to policy owners on their health care plan.  As an example, policy holders can select a plan that has either partial or full coverage for providers that are not part of the network, as well as full coverage on health care visits to network providers.

The biggest advantage of a point of service plan is that policy owners can opt to either see both network as well as non-network providers.  They also are not required to decide until it is time to see a provider.  With other types of plans, such as HMOs, users must only choose network providers.  There is not an option to see non-network providers even if the individual is willing to pay higher costs.

POS plans do have some similarities with HMO and PPO plans.  Just like an HMO plan, patients do not pay deductibles when they utilize network providers.  However,  there is usually a small co-pay when one sees a network provider.  The amount is usually around $10 to $15.

Another way in which POS and HMO plans are similar is that both types of plans require users to select primary care doctors that are members of the insurance carrier’s provider network.  However, one major difference is primary care doctors are able to refer policy holders to any specialist, whether the specialist is in or outside of the network.  Whether the specialist is part of the network or not, the insurance company will pay most of the costs of seeing a specialist.

The difference is referring out to a non-network specialist means that the policy holder will have to pay a deductible and a larger co-pay.  In this way POS plans work more like PPO plans.  In these situations, a co-pay could be as much as 40%.  The policy holder will also need to complete paperwork for the visit.

The yearly deductible on non-network health care usually runs $250-$300 for individuals and $500-$600 for families.

A majority of POS plans will provide coverage for these type of expenses:

• Primary care doctor visits
• Visits to specialists that your primary care doctor has referred you to (whether the specialist is part of the network or not)
• Diagnostic lab services and tests
• Emergency services
• Hospital services ( this includes both out and in patience services as well as diagnostic procedures)
• Preventative health care services, including checkups and vaccinations
• Prescription medicines
• Some plans also cover dental care

POS plans are useful for any individual who would like to have flexible health care insurance as well as have the ability to visit specialists without needing to worry about whether the specialist is part of their insurance carrier’s network or not for keeping expenses down.

However, selecting non-network providers on a consistent basis can get expensive quite fast.  PPO plans are best suited for families and individuals who can see network providers for most of their health care needs, but would like to have the option of choosing non-network specialists when it is a necessity.  If having the ability to self-refer is an important consideration, than PPOs are the ideal type of plan to choose.