"I get health insurance through my job. I have the coverage
I need... I think"
Find an HSA plan that's right for you. 
"I know I need a health insurance plan, but I'm not sure how to get
the best protection at the lowest cost."
You're not alone. Many people have questions about how to select a
health insurance plan. The information provided will help you find some answers.
"I can't afford health insurance right now. I have too many bills
to pay and other things I need to buy."
Health insurance is one of your most important needs. Without it,
one serious illness or accident could wipe you out financially. The information
provided will help you decide which is the best plan you can afford.
Return to Contents
Why Do You Need Health Insurance?
Today, health care costs are high, and getting higher. Who will
pay your bills if you have a serious accident or a major illness? You buy health
insurance for the same reason you buy other kinds of insurance, to protect
yourself financially. With health insurance, you protect yourself and your
family in case you need medical care that could be very expensive. You can't
predict what your medical bills will be. In a good year, your costs may be low.
But if you become ill, your bills could be very high. If you have insurance,
many of your costs are covered by a third-party payer, not by you. A third-party
payer can be an insurance company or, in some cases, it can be your employer.
Return to Contents
Where Do People Get Health Insurance Plans?
Find Affordable
Student Health Insurance 
Group Health Insurance
Most Americans get health insurance policies through their jobs or are
covered because a family member has insurance at work. This is called group
insurance. Group insurance is generally the least expensive kind. In many cases,
the employer pays part or all of the cost.
Some employers offer only one health insurance plan. Some
offer a choice of plans: a fee-for-service plan, a health maintenance
organization (HMO), or a preferred provider organization (PPO), for example.
Explanations of fee-for-service plans, HMOs, and PPOs are provided in the
section called Types of Insurance.
What happens if you or your family member leaves the job? You will
lose your employer-supported group coverage. It may be possible to keep the same
policy, but you will have to pay for it yourself. This will certainly cost you
more than group coverage for the same, or less, protection.
A Federal law makes it possible for most people to continue their
group health coverage for a period of time. Called COBRA (for the Consolidated
Omnibus Budget Reconciliation Act of 1985), the law requires that if you work
for a business of 20 or more employees and leave your job or are laid off, you
can continue to get health coverage for at least 18 months. You will be charged
a higher premium than when you were working.
You also will be able to get insurance under COBRA if your spouse
was covered but now you are widowed or divorced. If you were covered under your
parents' group plan while you were in school, you also can continue in the plan
for up to 18 months under COBRA until you find a job that offers you your own
health insurance.
Not all employers offer health insurance. You might find this to
be the case with your job, especially if you work for a small business or work
part-time. If your employer does not offer health insurance, you might be able
to get group insurance through membership in a labor union, professional
association, club, or other organization. Many organizations offer health
insurance plans to members.
Individual Health & Medical Insurance
Small Business Health Insurance Quotes 
If your employer does not offer group insurance, or if the
insurance offered is very limited, you can buy an individual policy. You can get
fee-for-service, HMO, or PPO protection. But you should compare your options and
shop carefully because coverage and costs vary from company to company.
Individual plans may not offer benefits as broad as those in group plans.
If you get a non cancellable policy (also called a guaranteed
renewable policy), then you will receive individual insurance under that policy
as long as you keep paying the monthly premium. The insurance company can raise
the cost, but cannot cancel your coverage. Many companies now offer a
conditionally renewable policy. This means that the insurance company can cancel
all policies like yours, not just yours. This protects you from being singled
out. But it doesn't protect you from losing coverage.
Before you buy any health insurance policy, make sure you know
what it will pay for...and what it won't. To find out about individual health
insurance plans, you can call insurance companies, HMOs, and PPOs in your
community, or speak to the agent who handles your car or house insurance.
Tips when shopping for individual insurance:
- Shop carefully. Policies differ widely in coverage and
cost. Contact different insurance companies, or ask your agent to show you
policies from several insurers so you can compare them.
- Make sure the policy protects you from large medical costs.
- Read and understand the policy. Make sure it provides the
kind of coverage that's right for you. You don't want unpleasant surprises when
you're sick or in the hospital.
- Check to see that the policy states: the date that the
policy will begin paying (some have a waiting period before coverage begins),
and what is covered or excluded from coverage.
- Make sure there is a "free look" clause. Most companies
give you at least 10 days to look over your policy after you receive it. If you
decide it is not for you, you can return it and have your premium refunded.
- Beware of single disease insurance policies. There are some
polices that offer protection for only one disease, such as cancer. If you
already have health insurance, your regular plan probably already provides all
the coverage you need. Check to see what protection you have before buying any
more insurance.
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There are many different types of health insurance. Each has pros
and cons. There is no one "best" plan. The plan that's right for a single person
may not be best for a family with small children. And a plan that works for one
family may not be right for another.
For example, if your family includes just two adults, it may be
less expensive for each of you to have individual coverage than for just one of
you to have a family plan. If you have children, or if you might have children
soon, you need a family plan. Because your situation may change, review your
health insurance regularly to make sure you have the protection you need.
Choosing a health insurance plan is like making any other major
purchase: You choose the plan that meets both your needs and your budget. For
most people, this means deciding which plan is worth the cost. For example,
plans that allow you the most choices in doctors and hospitals also tend to cost
more than plans that limit choices. Plans that help to manage the care you
receive usually cost you less, but you give up some freedom of choice.
Cost isn't the only thing to consider when buying health
insurance. You also need to consider what benefits are covered. You need to
compare plans carefully for both cost and coverage.
Although there are many names for health insurance plans, the
information here groups them as three main types:
- Fee-For-Service (or Traditional Health Insurance).
- Health Maintenance Organizations (or HMOs).
- Preferred Provider Organizations (or PPOs).
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Which Type Is Right for You?
For each group, choose the statement 1 or 2 that best describes
how you feel:
- Having complete freedom to choose doctors and hospitals is
the most important thing to me in a health plan, even if it costs more.
- Holding down my costs is the most important thing to me,
even if it means limiting some of my choices.
- I travel a lot or have children that live away from me and
we may need to see doctors in other parts of the country.
- I do not travel a lot and almost all care for my family
will be needed in our local area.
- I don't mind a health insurance plan that includes filling
out forms or keeping receipts and sending them in for payment.
- I prefer not to fill out forms or keep receipts. I want
most of my care covered without a lot of paperwork.
- In addition to my premiums, I am willing to pay for the
cost of routine and preventive care, such as office visits, checkups, and shots.
I also like knowing that I can get an appointment for these services when I want
one.
- I want a health plan that includes routine and preventive
care. I don't mind if I have to wait for these services to be scheduled for an
available appointment with my doctor.
- If I need to see a specialist, I probably will ask my
doctor for a recommendation, but I want to decide whom to go to and when. I
don't want to have to see my primary care doctor each time before I can see a
specialist.
- I don't mind if my primary care doctor must refer me to
specialists. If my doctor doesn't think I need special services, that is fine
with me.
If your answers are mostly 1: You want to make your own health
care choices, even if it costs you more and takes more paperwork.
Fee-for-service may be the best plan for you.
If your answers are mostly 2: You are willing to give up some
choices to hold down your medical costs. You also want help in managing your
care. Consider a health maintenance organization.
If your answers are some 1's and some 2's: You might want to look
for a plan such as a preferred provider organization that combines some of the
features of fee-for-service and a health maintenance organization.
The differences among fee-for-service plans, HMOs, and PPOs are
not as clear-cut as they once were. Fee-for-service plans have adopted some
activities used by HMOs and PPOs to control the use of medical services. And
HMOs and PPOs are offering more freedom to choose doctors, the way
fee-for-service plans do. By studying your health insurance options carefully,
you will be able to pick the one that provides you with the coverage you need,
no matter what it is called.
Managed Care: A Way to Control Costs
Managed care influences how much health care you use. Almost all
plans have some sort of managed care program to help control costs. For example,
if you need to go to the hospital, one form of managed care requires that you
receive approval from your insurance company before you are admitted to make
sure that the hospitalization is needed. If you go to the hospital without this
approval, you may not be covered for the hospital bill.
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Types of Insurance
Fee-for-Service
This is the traditional kind of health care policy. Insurance
companies pay fees for the services provided to the insured people covered by
the policy. This type of health insurance offers the most choices of doctors and
hospitals. You can choose any doctor you wish and change doctors any time. You
can go to any hospital in any part of the country.
With fee-for-service health insurance plans, the insurer only pays for part of your
doctor and hospital bills. This is what you pay:
- A monthly fee, called a premium.
- A certain amount of money each year, known as the
deductible, before the insurance payments begin. In a typical plan, the
deductible might be $250 for each person in your family, with a family
deductible of $500 when at least two people in the family have reached the
individual deductible. The deductible requirement applies each year of the
policy. Also, not all health expenses you have count toward your deductible.
Only those covered by the policy do. You need to check the insurance policy to
find out which ones are covered.
- After you have paid your deductible amount for the year,
you share the bill with the insurance company. For example, you might pay 20
percent while the insurer pays 80 percent. Your portion is called coinsurance.
To receive payment for fee-for-service claims, you may have to
fill out forms and send them to your insurer. Sometimes your doctor's office
will do this for you. You also need to keep receipts for drugs and other medical
costs. You are responsible for keeping track of your medical expenses.
There are limits as to how much an insurance company will pay for
your claim if both you and your spouse file for it under two different group
insurance plans. A coordination of benefit clause usually limits benefits under
two plans to no more than 100 percent of the claim.
Most fee-for-service plans have a "cap," the most you will have to
pay for medical bills in any one year. You reach the cap when your out-of-pocket
expenses (for your deductible and your coinsurance) total a certain amount. It
may be as low as $1,000 or as high as $5,000. Then the insurance company pays
the full amount in excess of the cap for the items your policy says it will
cover. The cap does not include what you pay for your monthly premium.
Some services are limited or not covered at all. You need to check
on preventive health care coverage such as immunizations and well-child care.
There are two kinds of fee-for-service coverage: basic and major
medical. Basic protection pays toward the costs of a hospital room and care
while you are in the hospital. It covers some hospital services and supplies,
such as x-rays and prescribed medicine. Basic coverage also pays toward the cost
of surgery, whether it is performed in or out of the hospital, and for some
doctor visits. Major medical insurance takes over where your basic coverage
leaves off. It covers the cost of long, high-cost illnesses or injuries.
Some policies combine basic and major medical coverage into one
plan. This is sometimes called a "comprehensive plan." Check your policy to make
sure you have both kinds of protection.
What Is a "Customary" Fee?
Most insurance plans will pay only what they call a reasonable and
customary fee for a particular service. If your doctor charges $1,000 for a
hernia repair while most doctors in your area charge only $600, you will be
billed for the $400 difference. This is in addition to the deductible and
coinsurance you would be expected to pay. To avoid this additional cost, ask
your doctor to accept your insurance company's payment as full payment. Or shop
around to find a doctor who will. Otherwise you will have to pay the rest
yourself.
Questions to Ask About Fee-for-Service Insurance
- How much is the monthly premium? What will your total cost
be each year? There are individual rates and family rates.
- What does the policy cover? Does it cover prescription
drugs, out-of-hospital care, or home care? Are there limits on the amount or the
number of days the company will pay for these services? The best plans cover a
broad range of services.
- Are you currently being treated for a medical condition
that may not be covered under your new plan? Are there limitations or a waiting
period involved in the coverage?
- What is the deductible? Often, you can lower your monthly
health insurance premium by buying a policy with a higher yearly deductible
amount.
- What is the coinsurance rate? What percent of your bills
for allowable services will you have to pay?
- What is the maximum you would pay out of pocket per year?
How much would it cost you directly before the insurance company would pay
everything else?
- Is there a lifetime maximum cap the insurer will pay? The
cap is an amount after which the insurance company won't pay anymore. This is
important to know if you or someone in your family has an illness that requires
expensive treatments.
Health Maintenance Organizations (HMOs)
Health maintenance organizations are prepaid health plans. As an
HMO member, you pay a monthly premium. In exchange, the HMO provides
comprehensive care for you and your family, including doctors' visits, hospital
stays, emergency care, surgery, lab tests, x-rays, and therapy.
The HMO arranges for this care either directly in its own group
practice and/or through doctors and other health care professionals under
contract. Usually, your choices of doctors and hospitals are limited to those
that have agreements with the HMO to provide care. However, exceptions are made
in emergencies or when medically necessary.
There may be a small copayment for each office visit, such as $5
for a doctor's visit or $25 for hospital emergency room treatment. Your total
medical costs will likely be lower and more predictable in an HMO than with
fee-for-service insurance.
Because HMOs receive a fixed fee for your covered medical care, it
is in their interest to make sure you get basic health care for problems before
they become serious. HMOs typically provide preventive care, such as office
visits, immunizations, well-baby checkups, mammograms, and physicals. The range
of services covered vary in HMOs, so it is important to compare available plans.
Some services, such as outpatient mental health care, often are provided only on
a limited basis.
Many people like HMOs because they do not require claim forms for
office visits or hospital stays. Instead, members present a card, like a credit
card, at the doctor's office or hospital. However, in an HMO you may have to
wait longer for an appointment than you would with a fee-for-service plan.
In some HMOs, doctors are salaried and they all have offices in an
HMO building at one or more locations in your community as part of a prepaid
group practice. In others, independent groups of doctors contract with the HMO
to take care of patients. These are called individual practice associations
(IPAs) and they are made up of private physicians in private offices who agree
to care for HMO members. You select a doctor from a list of participating
physicians that make up the IPA network. If you are thinking of switching into
an IPA-type of HMO, ask your doctor if he or she participates in the plan.
In almost all HMOs, you either are assigned or you choose one
doctor to serve as your primary care doctor. This doctor monitors your health
and provides most of your medical care, referring you to specialists and other
health care professionals as needed. You usually cannot see a specialist without
a referral from your primary care doctor who is expected to manage the care you
receive. This is one way that HMOs can limit your choice.
Before choosing an HMO, it is a good idea to talk to people you
know who are enrolled in it. Ask them how they like the services and care given.
Questions to Ask About an HMO
- Are there many doctors to choose from? Do you select from a
list of contract physicians or from the available staff of a group practice?
Which doctors are accepting new patients? How hard is it to change doctors if
you decide you want someone else? How are referrals to specialists handled?
- Is it easy to get appointments? How far in advance must
routine visits be scheduled? What arrangements does the HMO have for handling
emergency care?
- Does the HMO offer the services I want? What preventive
services are provided? Are there limits on medical tests, surgery, mental health
care, home care, or other support offered? What if you need a special service
not provided by the HMO?
- What is the service area of the HMO? Where are the
facilities located in your community that serve HMO members? How convenient to
your home and workplace are the doctors, hospitals, and emergency care centers
that make up the HMO network? What happens if you or a family member are out of
town and need medical treatment?
- What will the HMO plan cost? What is the yearly total for
monthly fees? In addition, are there copayments for office visits, emergency
care, prescribed drugs, or other services? How much?
Preferred Provider Organizations (PPOs)
The preferred provider organization is a combination of
traditional fee-for-service and an HMO. Like an HMO, there are a limited number
of doctors and hospitals to choose from. When you use those providers (sometimes
called "preferred" providers, other times called "network" providers), most of
your medical bills are covered.
When you go to doctors in the PPO, you present a card and do not
have to fill out forms. Usually there is a small copayment for each visit. For
some services, you may have to pay a deductible and coinsurance.
As with an HMO, a PPO requires that you choose a primary care
doctor to monitor your health care. Most PPOs cover preventive care. This
usually includes visits to the doctor, well-baby care, immunizations, and
mammograms.
In a PPO, you can use doctors who are not part of the plan and
still receive some coverage. At these times, you will pay a larger portion of
the bill yourself (and also fill out the claims forms). Some people like this
option because even if their doctor is not a part of the network, it means they
don't have to change doctors to join a PPO.
Questions to Ask About a PPO
- Are there many doctors to choose from? Who are the doctors
in the PPO network? Where are they located? Which ones are accepting new
patients? How are referrals to specialists handled?
- What hospitals are available through the PPO? Where is the
nearest hospital in the PPO network? What arrangements does the PPO have for
handling emergency care?
- What services are covered? What preventive services are
offered? Are there limits on medical tests, out-of-hospital care, mental health
care, prescription drugs, or other services that are important to you?
- What will the PPO plan cost? How much is the premium? Is
there a per-visit cost for seeing PPO doctors or other types of copayments for
services? What is the difference in cost between using doctors in the PPO
network and those outside it? What is the deductible and coinsurance rate for
care outside of the PPO? Is there a limit to the maximum you would pay out of
pocket?
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Checklist: What's Most Important to You?
Insurance plans vary. Before choosing a plan, decide what is most
important to you. This checklist can help. Put a check in front of those
services that are important to you. Then see how many of these services are in
Policy #1, Policy #2, and Policy #3. On the checklist, write in the coinsurance
or copayment rate, if there is one, and any limits on service.
Remember that the most important service to be covered is
hospitalization. If you are not covered for hospital care, then one sickness
could cost you thousands of dollars, even hundreds of thousands of dollars.
Service Policy #1 Policy #2 Policy #3
-Hospital care
-Surgery (inpatient
and outpatient)
-Office visits to
your doctor
-Maternity care
-Well-baby care
-Immunizations
-Mammograms
-Medical tests,
x-rays
-Mental health care
-Dental care,
braces and cleaning
-Vision care,
eyeglasses and exams
-Prescription drugs
-Home health care
-Nursing home care
-Services you need
that are excluded
Other issues that are
important to you:
-Choice of doctors
-Convenient location of
doctors and hospitals
-Ease of getting
an appointment
-Minimal paperwork
-Waiting period before
coverage begins
Which policy is best for you?
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It is difficult to determine exactly what you will spend a year on
health care. You do not know whether you will be sick 6 months from now and need
an operation. Hopefully, you will not.
Using this worksheet, you can begin to make some rough estimates.
Much will depend on what service you need or want, how many people are in your
family, your age, and other factors. Do you need to have your eyes tested this
year? Will you have a mammogram or other cancer screening test? Does your child
need immunizations?
Look at your medical and insurance records from last year as a
guide to what services you might use this year. Add up the actual costs to you,
including premiums. Estimate what you might spend on your health care in terms
of deductibles, coinsurance and/or co-payments, and services that are not
covered.
Compare Policy #1, Policy #2, and Policy #3 to determine which is
the best buy for you.
What is your monthly premium? Policy #1 Policy #2 Policy #3
Individual:
Family:
Multiply by 12 for annual cost:
What is your deductible?
(if there is one)
Individual:
Family:
What is your coinsurance rate
or copayment, if there is one?
(Note if there is a higher rate
for special services, such as
outpatient mental health care.)
Are there any annual limits for
days or services covered and
the amount spent on you?
What is the maximum you will have
to pay out-of-pocket each year?
What is the lifetime limit,
if any,that you will be
reimbursed?
Total estimated yearly cost
to you:
Now look at the checklist of services that are important to you.
Is your best buy the same policy that gives you the most services you need?
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Other Types of Insurance
Medicare is the Federal health insurance program for Americans age
65 and older and for certain disabled Americans. If you are eligible for Social
Security or Railroad Retirement benefits and are age 65, you and your spouse
automatically qualify for Medicare.
Medicare has two parts: hospital insurance, known as Part A, and
supplementary medical insurance, known as Part B, which provides payments for
doctors and related services and supplies ordered by the doctor. If you are
eligible for Medicare, Part A is free, but you must pay a premium for Part B.
Medicare will pay for many of your health care expenses, but not
all of them. In particular, Medicare does not cover most nursing home care,
long-term care services in the home, or prescription drugs. There are also
special rules on when Medicare pays your bills that apply if you have employer
group health insurance coverage through your own job or the
Search Insurance Providers by Zip Code Here!of a spouse.
Medicare usually operates on a fee-for-service basis. HMOs and
similar forms of prepaid health care plans are now available to Medicare
enrollees in some locations.
The best source of information on the Medicare program is the
Medicare Handbook. This booklet explains how the Medicare program works and
what your benefits are. To order a free copy, write to: Health Care Financing
Administration, Publications, N1-26-27, 7500 Security Blvd., Baltimore, MD
21244-1850. You also can contact your local Social Security office for
information.
Some people who are covered by Medicare buy private insurance,
called "Medigap" policies, to pay the medical bills that Medicare doesn't cover.
Some Medigap policies cover Medicare's deductibles; most pay the coinsurance
amount. Some also pay for health services not covered by Medicare. There are 10
standard plans from which you can choose. (Some States may have fewer than 10.)
If you buy a Medigap policy, make sure you do not purchase more than one.
You need to shop carefully before deciding on the best policy to
fit your needs. You may get another booklet, Guide to Health Insurance for
People with Medicare, to help you in making the right choice. To order a
free copy, write to: Health Care Financing Administration, Publications,
N1-26-27, 7500 Security Blvd., Baltimore, MD 21244-1850.
Another good source of information on the same topic is The
Consumer's Guide to Medicare Supplement Insurance. To order a free copy,
write to: Health Insurance Association of America, 555 13th St., N.W., Suite 600
East, Washington, D.C. 20004.
Medicaid
Medicaid provides health care coverage for some low-income people
who cannot afford it. This includes people who are eligible because they are
aged, blind, or disabled or certain people in families with dependent children.
Medicaid is a Federal program that is operated by the States, and each State
decides who is eligible and the scope of health services offered.
General information on the Medicaid program is given in the
Medicaid Fact Sheet. For a free copy, write to: Health Care Financing
Administration, Publications, N1-26-27, 7500 Security Blvd., Baltimore, MD
21244-1850. For specifics on Medicaid eligibility and the health services
offered, contact your State Medicaid Program Office.
Disability Insurance
Disability insurance replaces income you lose if you have a
long-term illness or injury and cannot work. This is an important type of
coverage for working-age people to consider. Disability insurance does not cover
the cost of rehabilitation if you are injured. Check your major medical
insurance to see if it is covered there.
Some employers offer group disability insurance and this may be
one of the benefits where you work. Or you might be eligible for some
government-sponsored programs that provide disability benefits. Many different
kinds of individual policies are also available.
The Consumer's Guide to Disability Insurance explains
disability insurance and sources of disability income to help you decide if you
need this coverage. It will also help you compare your choices of policies. For
a free copy, write to: Health Insurance Association of America, 555 13th St.,
N.W., Suite 600 East, Washington, D.C. 20004.
Hospital Indemnity Insurance
This insurance offers limited coverage. It pays a fixed amount for
each day, up to a maximum number of days. You may use it for medical or other
expenses. Usually, the amount you receive will be less than the cost of a
hospital stay.
Some hospital indemnity policies will pay the specified daily
amount even if you have other health insurance. Others may coordinate benefits,
so that the money you receive does not equal more than 100 percent of the
hospital bill.
Long-term care insurance is designed to cover the costs of nursing
home care, which can be several thousand dollars each month. Long-term care is
usually not covered by health insurance except in a very limited way. Medicare
covers very few long-term care expenses. There are many plans and they vary in
costs and services covered, each with its own limits.
More detailed information is given in A Shopper's Guide to
Long-Term Care Insurance. Contact your State Insurance Department or write:
National Association of Insurance Commissioners, 120 W. 12th Street, Suite 1100,
Kansas City, MO 64105.
Another good source of information is The Consumer's Guide to
Long-Term Care Insurance. For a free copy, write to: Health Insurance
Association of America, 555 13th St., N.W., Suite 600 East, Washington, D.C.
20004.
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A Final Word
There's no doubt that choosing among health insurance plans takes
time and effort. Now that you have read this information, you know what
questions to ask so you will be able to carefully compare various plans and find
the one that best fits your needs.
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Understanding Health Insurance Terms
Coinsurance: The amount you are required to pay for medical care
in a fee-for-service plan after you have met your deductible. The coinsurance
rate is usually expressed as a percentage. For example, if the insurance company
pays 80 percent of the claim, you pay 20 percent.
Coordination of Benefits: A system to eliminate duplication of
benefits when you are covered under more than one group plan. Benefits under the
two plans usually are limited to no more than 100 percent of the claim.
Copayment: Another way of sharing medical costs. You pay a flat
fee every time you receive a medical service (for example, $5 for every visit to
the doctor). The insurance company pays the rest.
Covered Expenses: Most insurance plans, whether they are
fee-for-service, HMOs, or PPOs, do not pay for all services. Some may not pay
for prescription drugs. Others may not pay for mental health care. Covered
services are those medical procedures the insurer agrees to pay for. They are
listed in the policy.
Deductible: The amount of money you must pay each year to cover
your medical care expenses before your insurance policy starts paying.
Exclusions: Specific conditions or circumstances for which the
policy will not provide benefits.
HMO (Health Maintenance Organization): Prepaid health plans. You
pay a monthly premium and the HMO covers your doctors' visits, hospital stays,
emergency care, surgery, checkups, lab tests, x-rays, and therapy. You must use
the doctors and hospitals designated by the HMO.
Managed Care: Ways to manage costs, use, and quality of the health
care system. All HMOs and PPOs, and many fee-for-service plans, have managed
care.
Maximum Out-of-Pocket: The most money you will be required pay a
year for deductibles and coinsurance. It is a stated dollar amount set by the
insurance company, in addition to regular premiums.
Noncancellable Policy: A policy that guarantees you can receive
insurance, as long as you pay the premium. It is also called a guaranteed
renewable policy.
PPO (Preferred Provider Organization): A combination of
traditional fee-for-service and an HMO. When you use the doctors and hospitals
that are part of the PPO, you can have a larger part of your medical bills
covered. You can use other doctors, but at a higher cost.
Preexisting Condition: A health problem that existed before the
date your insurance became effective.
Premium: The amount you or your employer pays in exchange for
insurance coverage.
Primary Care Doctor: Usually your first contact for health care.
This is often a family physician or internist, but some women use their
gynecologist. A primary care doctor monitors your health and diagnoses and
treats minor health problems, and refers you to specialists if another level of
care is needed.
Provider: Any person (doctor, nurse, dentist) or institution
(hospital or clinic) that provides medical care.
Third-Party Payer: Any payer for health care services other than
you. This can be an insurance company, an HMO, a PPO, or the Federal Government.
Additional Resources:
For more current information on health insurance and health
plan choice, select
Choosing and Using a Health Plan or
Your Guide to Choosing Quality Health Care.
Return to Contents
Internet Citation:
Checkup on Health Insurance Choices. AHCPR
Publication No. 93-0018, December 1992. Agency for Health Care Policy and
Research, Rockville, MD. http://www.ahrq.gov/consumer/insuranc.htm
Return
to Consumers & Patients
AHRQ Home Page
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