Individual Health Insurance: Find the Right Plan
The costs of health care and health insurance continue to climb and the importance of protecting your family and finances has never been greater. Often times, individuals do not have access to a group plan through an employer and need expert advice on navigating the complexities of individual health insurance. Bob Gabriel Company represents most of the major individual health insurance providers in California: Aetna, Anthem Blue Cross, Health Net, and PacifiCare.
Providing individual health insurance for yourself and your family is more than just a health plan. It’s also about understanding the coverage. Contact us now and we can help you pick the best individual health insurance plan.
Whether you are buying individual insurance for yourself or family members, making decisions regarding a group health plan for your company, or selecting among options as an employee being offered health insurance choices, the following questions will help you to narrow down the right type of policy for your situation.
Each of us approaches the health care issue with a unique set of needs. How much risk do I want to take for health expenses, and what am I willing to pay to lower those risks are two that are right at the top of the list. Are you and the others in your family basically in good health? Does anyone have a pre-existing conditions to consider?
- How comprehensive do you want health care coverage to be?
- Am I willing to limit my choices of physicians and hospitals?
- If I need a specialist, am I willing to rely on my primary care doctor to referring me for additional care?
- What kind of trade offs am I willing to make for convenience vs costs?
- Just how important is the cost of services? Am I willing to pay more at the doctors office so that I can pay less in monthly premiums.
- Am I willing to pay in advance, then keep receipts and file a claim to save money? Or would I rather pay a copay and know that everything is covered.
- Am I about to experience any life changes that might effect medical issues or available income for coverage, such as starting a family or retiring.
- How will various choices impact family members who have chronic health conditions or disabilities.
At a minimum, you’ve got to understand the difference between health maintenance organizations (HMOs) and preferred provider organizations (PPOs) and its variants, which are the two basic types of health insurance plans offered today. By and large PPOs are more expensive than HMO’s. HMO members select a primary care physician (PCP) from a list of member physicians. The PCP provides basic medical care. The PCP must recommend that you see a specialist when needed, and the specialist must also be a member of the HMO list. With a PPO members do not have to choose a primary care physician from an approved list, but there is usually a financial incentive to do so. PPO members can refer themselves to specialists without going through a “gatekeeper” at the insurance company for approval of the appointment.
HMOs provide virtually no coverage for care outside of the HMO physician network except while traveling. HMO members usually pay a nominal co-payment for each visit to a PCP or specialist . PPOs generally require a deductible (especially for hospitalization) and may have larger co-payments than HMOs.
Specific policy elements that you may want to consider in detail:
- Physical exams and health screenings. Is there a cost for an annual physical? Do you think you will take advantage of a low copay if offered?
- Prescription drugs. What is the copay? Does the copay only cover generics if there is an acceptable generic substitute?
- Hospitalization and emergency care. What is the copay, daily rate, deductible and maximums for each event.
- Care and counseling for mental health. How many sessions per year? Must you select mental health professionals from a list?
- Services for drug and alcohol abuse. Are these covered? What kind of facilities are covered?
- Vision Care and Dental Services. What is covered? Are you likely to need this coverage?
- Ongoing care for chronic (long-term) diseases, conditions, or disabilities. If you know there are specific issues, ask the agent to help you explore these very carefully.
- Physical therapy and other rehabilitative care. What are the copay costs and limitations of the policy?
- Obstetrical-gynecological care and family planning services. Are there any limitations on these services that might be important to you?
- Chiropractic or alternative health care, such as acupuncture. If these types of care are important to you, find out what is and isn’t covered?
- Home health, nursing home, and hospice care. This should be an area that is easy to plan for? Is this policy the right one for you when this time has come?
- What health screenings are offered, (e.g. Pap Smears and breast exams?)
- If you are a smoker or obese, are there specific services available for you?
- What preventive care is offered, such as shots for children?
A major difference between policies is how much you pay and when. Some policies have larger premiums that result in you paying little or nothing for services when you need them. Other policies have very low premiums, but when you do need health care, you pay more for each event. If you are young and healthy and don’t mind taking more risks, you might opt for the less expensive policy. If you are older, more likely to be needing various services, or prefer to have more security and less risk, then the more inclusive policies are right for you.
Here are things to consider:
- Are there deductibles you pay out of pocket before the insurance starts coverage?
- When you have reached the deductible amount in any given year, what does the plan now cover?
- What are the co-payments for services, such as doctor visits, prescriptions, emergency rooms or urgent care?
- If you use doctors or other services outside the plan’s network, what does the plan cover and how much difficulty is there in getting reimbursed?
- If a policy seems perfect in every way, but does not cover certain services you expect to need, what are your likely costs out of pocket?
- Are there maximums that the insurance covers in case of a major illness where you must pay amounts over that maximum limit?
- Are there other limits of maximums that this policy will pay for your care in a single year? in a lifetime? What are you willing to accept as a risk on such limitations.
Health Insurance Costs Explained
Have you ever taken a moment to have someone explain health insurance costs to you? We know that health insurance costs just keep going up and up, but how do these spiraling costs affect your health insurance coverage? You know the amount you’re paying every month for your health insurance premium, so it’s easy to know when this cost increases, but what about all the other costs involved with health insurance? Do you know what they mean? Before you’re hit with an excessively large medical bill, read the following explanation of health insurance costs.
- Premium: The premium is the amount you’ll pay for the benefits covered under your health insurance plan. The premium is typically broken down into equal monthly payments. If you’ve got group insurance, your employer or a union is probably sharing some percentage of this cost.
- Deductible: If your health insurance policy includes an annual deductible, it’s important to understand the details. A deductible is an amount that you are responsible for paying before the insurance company begins paying out claims. As with car insurance, the higher your deductible the lower your monthly premium and vice versa. A family health insurance plan typically includes multiple deductibles.
- Co-Payment: A co-payment is a fixed amount that the insured has to pay each time they visit the doctor. The co-payment amount differs based on the type of health insurance plan you have and typically an HMO will have the lowest co-payment. The co-payment can however, increase for different types of medical service and/or if you go outside the network.
- Co-Insurance: . Co-Insurance is the amount of a claim that the insured is responsible for paying, once the deductible has been met. A typical ratio is 80/20 where the insurance company pays 80% of a claim and the insured pays 20%. An insured’s percentage will typically increase when he goes outside the network. Also, in situations where the claim exceeds what the insurance company deems ‘reasonable and customary’ the difference is another form of co-insurance that must be paid by the insured.
If you don’t fully understand these health insurance costs have someone explain them to you. These are the things you’ve got to ask about when requesting quotes, especially online health insurance quotes. When you’re comparing quotes from different insurance companies, it’s important to know all your costs, not just the premium. Make sure the person preparing your quote clearly defines the deductible amount and whether there is a separate deductible for different types of services, the co-payment amount and the co-insurance amounts. Also ask the person to elaborate on other costs that may not be readily apparent.
Now that you’ve determined your needs and reviewed the benefits and costs offered by each plan, it’s almost time for you to make a decision. The last few criteria you should consider other than costs and benefits are choice, location, and quality. While the idea plan would cover 100% of all your needs, for free, with the best quality care, in reality, you will need to make important tradeoffs between each of these criteria.
- Choice – What doctors, hospitals, and other medical providers are part of the plan? Are there enough of the kinds of doctors you want to see? Do you need to choose a primary care doctor? If you want to see a specialist, can you refer yourself or must your primary care doctor refer you? Do you need approval from the plan before going into the hospital or getting specialty care?
- Location – Where will you go for care? Are these places near where you work or live? How does the plan handle care when you are away from home?
- Quality of Care – Quality is hard to measure, but more and more information is becoming available. There are certain things you can look for and questions you can ask. Whatever kind of plan you are considering, you can check out individual doctors and hospitals.
- Talk to current members Ask how they feel about their experiences, such as waiting times for appointments, the helpfulness of medical staff, the services offered, and the care received. If there are programs for your particular condition, how are the patients in it doing
- Report cards Some plans and independent organizations are also beginning to produce “report cards.” These reports often include satisfaction survey results and other information on quality, such as if a plan provides preventive care (for example, shots for children and Pap smears for women) or if the plan follows up on test results. Also be on the lookout for magazine articles rating various health plans.
- Accreditation You can also find out if the managed care plan you are interested in has been “accredited,” meaning that it meets certain standards of independent organizations. Some States require accreditation if plans serve special groups, such as people in Medicaid. Some employers will only contract with plans that are accredited.
- Financial Strength Is the insurance company financially sound and able to pay all it’s claims? This is an important consideration for smaller less known plans. Such financial disclosers are usually disclosed/regulated by state agencies as well as 3rd party accreditation services and reports.
- Operational Questions Ask a plan representative about how the organizatoin screens doctors/nurses, address problems, and other processes meant to sustain and improve the quality of care.