Look at a new health insurance plan?

Many people face the confusing proposition of choosing health insurance.  To help navigate the process, here are a few questions you should be asking to help find what is right for you.

1) What type of plan is it?

Are you considering an indemnity health plan or a managed care system?  With an indemnity plan, also called fee-for-service plans, you pay a percentage of the overall cost and are typically allowed to choose your own doctors.

With managed care systems, usually either a HMO or PPO, you can limited out-of-pocket cost, but may be restricted in which doctors you can see or what facilities you can use.  With some plans you will be able to see doctors out of network but be required to pay more.

Learn more about PPO & HMO

2) How much will I need to pay for medical care?

What is the monthly premium that you will need to pay?  Find out also what your cost share is.  Some plans require a flat fee of only a few dollars, while others have a deductible that you have to meet before the plans starts to pay.

3) How much will this plan actually cost me?

The total cost of the plan is more than just the premiums.  Find out what your max-out-of-pocket amount is for each year.  This, plus your premiums each month, is how much you could need to pay.  For people that visit the doctor a lot, paying a higher premium each month may result in lower overall cost.

4) Do I need to change doctors or can I keep my current ones?

Ask if you can keep your current doctor.  Are there limits on the hospitals that you can use?  Some plans require that you use only doctors and facilities in their network while others have no restrictions on where you can go.

5) Are other benefits included?

Ask if the plan covers dental, vision, or other special services that you might need.  Make sure to ask about prescriptions also.

6) Are routine exams covered?

Most insurances plans cover an annual physical exam once a year, but may exclude the cost associated with lab analysis.  Some plans require you to pay a specific amount for certain test.  Make sure to ask about immunizations, mammograms, and other routine check-ups.

With the introduction of the ACA, most preventative services are covered by health insurance plans.

Learn more about preventative care

7) Do I need to call my doctor before going to the ER?

Some plans require that you call your doctor within 24 hours of visiting he emergency room, or your plan will not pay the cost.  Others require that you call before you are admitted.

8) How does this plan treat pre-existing conditions?

The Affordable Care Act made it so that insurance companies can not deny coverage if you have a pre-existing health issue.  You also can not be charged more because of this issue.

Some plans however are exempt from this.  While they are not sold on the Marketplace, insurance companies can sell them directly, or they can be bought through insurance agents.  The protections granted through the ACA may not apply to these plans and your pre-existing condition may end up costing you more.

Learn more about the Affordable Care Act

9) What happens when I need care and I'm away from home?

Most plans cover emergency room visits and urgent care services out of state.  For non-emergency services you may require prior approval for you insurance company to pay, or you may be required to pay a higher cost share.  Make sure that you understand what is and isn’t covered when you’re away from home, and what portion of the cost is yours.

10) How does the insurance company handle claim disputes?

All insurance companies have procedures for how they appeal denied claims.  Some require you take your dispute to an arbitrator.  Ask what the company’s average turn-around time is for resolving disputes.

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