What are you buying when you purchase health insurance, and how do you know if you are getting a good deal? The answers to these questions depend on your understanding a few basic health insurance concepts. Don’t worry, these are easy to grasp and well worth the time when you start shopping for the best, low cost health insurance. The point of this article is to help guide you through these basics so that you better understand what you are getting when you buy a health insurance plan.
One of the first things to understand is that when you purchase health insurance, just as with any kind of insurance, you are purchasing a sort of contract that guarantees you a specific set of benefits. In order to remain eligible to receive those benefits, you pay a recurring, monthly fee which is called a premium. The premium is the insurance company’s fee for managing the risk of your need for health insurance coverage. At bottom, all insurance is risk management, and you are essentially paying the insurer to assume the risk of payment for health care.
When you shop for health insurance, you discover that there are many different kinds and packages. For many people, health insurance means a coverage that pays the bills for doctor visits, outpatient hospital care, and inpatient stays. However, there are other kinds as well, such catastrophic health coverage, maternity coverage, and dismemberment insurance to name just a few examples. When you search for health coverage, you find an assortment of plans each offering its own package of benefits with its own rate of payment. The insurance plan is the “package” of benefits, and the benefits describe exactly what the insurer will pay for. For this reason, it is important that you understand the package so that you know what to expect when you receive health care.
Some of the kinds of insurance plans most commonly sold are health maintenance organizations (HMOs), preferred provider organizations (PPOs), and private fee for service plans (PFFSs). The HMO, PPO, and PFFS are different ways of packaging benefits. That means that each kind of plan will pay for different kinds of services and each plan will have different payment rates. A payment rate is how much they will pay health care providers for their services. HMOs are usually less expensive but generally require you to get all of your care only from providers in the plan’s pre-determined network of doctors and hospitals. In an HMO you would be assigned a Primary Care physician, and a referral from that doctor would be required in order to see a specialist. Quite often, HMOs work better for individuals who in relatively good health and whose medical needs are not terribly demanding.
PPOs generally offer greater flexibility of coverage than HMOs. Whereas HMOs require that you receive care only from network providers, PPOs allow you to go out-of-network and do not require referrals. PPOs also include network providers (doctors and hospitals who have a contract to provide care to plan members), and care within the network will always be less expensive than going out-of-network. PPOs are often more expensive than HMOs but are generally considered to offer more coverage. You can see that if you understand you and your family’s needs, you can determine whether a less expensive HMO or the more expensive PPO would be appropriate. Even though a PPO may be more expensive, if it more adequately meets your needs, it may less expensive in the long run. Some examples of the big health insurance names you may encounter include United Health Care, Humana, Blue Cross, Blue Shield, Aetna, Cigna, Anthem, Tonik, Wellmark, and John Deere.
A private fee for service plan (PFFS) is yet another kind of managed care. However, this sort of plan does not require you to receive care from a network of providers. In the PFFS plan you can receive care from any doctor, hospital, or other health care provider who accepts the plans payment terms. It is advisable that you always check with your providers first before receiving services to be sure that they will, in fact, submit claims to the insurance company. In a PFFS, instead of offering a package of fixed benefits (as in an HMO and PPO), the company pays a set fee for each service you receive that the provider bills to the insurer.
Just what are the real costs of a health insurance policy? The answer to that question will depend in part on the cost of monthly premiums, the deductibles, and the co-pays and co-insurances that you can expect to pay. There is another factor as well that is often ignored, and that is the reliability of the insurance company. If possible, you want to get the best idea you can of the actual reputation of the company for meeting its coverage obligations. In other words, is the company going to pay on the claims per the policy agreement, or will you have to fight every step of the way for your health care. You can see that a plan with a cheap premium could turn out to cost more than a more expensive plan if less expensive plan refuses to pay the medical claims.
It is possible to find cheap quotes for health insurance, but the secret to getting a low cost plan lies in paying only for the key services you need. Basically, then, you want to remove from a policy every benefit you can do without and then assume as high a deductible as possible. And again, you want to undertake the due diligence to establish the company’s reliability. In a time of need, it is vital that the insurer pay in a timely fashion without argument.
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