Frequently Asked Questions
Q What is the first thing I should know about buying health coverage?
A Your aim should be to insure yourself and your family against the most serious and financially disastrous losses that can result from an illness or accident. If you are offered health benefits at work, carefully review the plans’ literature to make sure the one you select fits your needs. If you purchase individual coverage, buy a policy that will cover major expenses and pay them to the highest maximum level. Save money on premiums, if necessary, by taking large deductibles and paying smaller costs out-of-pocket.
Q Can I buy a single health insurance policy that will provide all the benefits I’m likely to need?
A No. Although you can select a plan or buy a policy that should cover most medical, hospital, surgical, and pharmaceutical bills, no single policy covers everything. Moreover, you may want to consider additional single-purpose policies like long-term care or disability income insurance. If you are over 65, you may want a Medicare supplement policy to fill in the gaps in Medicare coverage.
Q I’m planning to keep working after age 65. Will I be covered by Medicare or by my company’s health insurance?
A If you work for a company with 20 or more employees, your employer must offer you (through age 69) the same health insurance coverage offered to younger employees. After you reach age 65, you may choose between Medicare and your company’s plan as your primary insurer. If you elect to remain in the company plan, it will pay first – for all benefits covered under the plan – before Medicare is billed. In most instances, it is to your advantage to accept continued employer coverage.
But be sure to enroll in Medicare Part A, which covers hospitalization and can supplement your group coverage at no additional cost to you. You can save on Medicare premiums by not enrolling in Medicare Part B until you finally retire. Bear in mind, though, that delayed enrollment is more expensive and entails a waiting period for coverage.
Q I’ve had a serious health condition that appears to be stabilized. Can I buy individual health coverage?
A Depending on what your condition is and when it was diagnosed and treated, you can probably buy health coverage. However, the insurer may do one of three things:
provide full protection but with a higher premium, as might be the case with a chronic disease, such as diabetes;
modify the benefits to increase the deductible;
exclude the specific medical problem from coverage, if it is a clearly defined condition, as long as the insurer abides by state and federal laws on exclusions.
Q One of my medical bills was turned down by the insurance company (or health plan). Is there anything I can do?
A Ask the insurance company why the claim was rejected. If the answer is that the service isn’t covered under your policy, and you’re sure that it is covered, check to see that the provider entered the correct diagnosis or procedure code on the insurance claim form. Also check that your deductible was correctly calculated.
Make sure that you didn’t skip an essential step under your plan, such as pre admission certification. If everything is in order, ask the insurer to review the claim.
Whether you end up choosing a fee-for-service plan or a form of managed care, you must examine a benefits summary or an outline of coverage – the description of policy benefits, exclusions, and provisions that makes it easier to understand a particular policy and compare it with others.
Look at this information closely. Think about your personal situation. After all, you may not mind that pregnancy is not covered, but you may want coverage for psychological counseling. Do you want coverage for your whole family or just yourself? Are you concerned with preventive care and checkups? Or would you be comfortable in a managed care setting that might restrict your choice somewhat but give you broad coverage and convenience? These are questions that only you can answer.
Here are some of the things to look at when choosing and comparing health insurance plans.
Health Insurance Checklist
Covered medical services
- Inpatient hospital services
- Outpatient surgery
- Physician visits (in the hospital)
- Office visits
- Skilled nursing care
- Medical tests and X-rays
- Prescription drugs
- Mental health care
- Drug and alcohol abuse treatment
- Home health care visits
- Rehabilitation facility care
- Physical therapy
- Speech therapy
- Hospice care
- Maternity care
- Chiropractic treatment
- Preventive care and checkups
- Well-baby care
- Dental care
- Other covered services
Are there any medical service limits, exclusions, or preexisting conditions that will affect you or your family?
What types of utilization review, pre authorization, or certification procedures are included?
How much is the premium?
Are there any discounts available for good health or healthy behaviors (e.g., non-smoker)?
How much is the annual deductible?
$_________________________________ per person
$_________________________________ per family
What coinsurance or co-payments apply?
_________________________________% after I meet my deductible
$_________________________________copay or % coinsurance per office visit
$_________________________________copay or % coinsurance for “wellness” care (includes well-baby care, annual eye exam, physical, etc.)
$_________________________% copay or coinsurance for inpatient hospital care