| Insurance Plans |
There are many new kinds of insurance plans and so many new terms, it can be difficult to understand WHAT YOU SHOULD DO when you need health services.
When seeking medical services, with any insurance plan, you will need to identify the type of insurance you have and present your insurance card. Remember - if the insurance information is not given or is filled out incorrectly you will be responsible for any incurred costs.
Below are a few guidelines that apply to most insurance companies. Plans do vary so it is best to review the insurance information with your parents and/or insurance carriers:
HMO's (Health Maintenance Organizations) - A health plan that combines coverage of health care costs and delivery of health care for a pre-paid premium. Members receive service from personnel employed by or under contract to the HMO. HMO's generally require patients to select a PCP who coordinates the patient's care. Advantages: emphasizes preventative care, minimal out-of-pocket payment (co-pay), rarely a need to file a health insurance claim. Disadvantages: Restricted access to physicians, must go through PCP before going to hospital or specialists, to have additional services and for tests from specialist or hospital you must have a referral from PCP. If you do not use your PCP to access care, you may be responsible for the entire bill.
PPO (Preferred Provider Organization) - A network of independent physicians, hospitals and other health care providers who contract with an insurance entity to provide care at discount rates. Members are given incentives to use the PPO physician, but are always allowed to use out-of-network providers at a higher cost. Advantages: Can go out of network for care, minimal out-of-pocket expense with network health care providers, rarely need to file an insurance claim. Disadvantages: 20-30% increase in out-of-pocket expense if going out of network for care.
POS (Point of Service) - A mix between PPO & HMO's. Like HMO's, POS plans require you to choose. But, like a PPO, you have the option of seeing a non-participating physician and paying a larger share of the cost. Advantages: Emphasize both primary and preventative care, minimal out of pocket co-payment when in network care, can choose to see out-of-network physicians. Disadvantages: 20-30% increase in out-of-pocket expense to go out of network.
Traditional or Indemnity Plans (fee for services) - This type of benefit plan offers a wide range of health services and you may use the hospital and/or physician of your choice. The plan design will determine how much out-of-
pocket expense you will pay to receive these services. Advantages: Can choose any physician or hospital for care, no need for referrals. Disadvantages: must complete and forward claim forms to insurance, may need pre-certification (pre-approval) if going to hospital or having surgery, out-of-pocket costs may be high.
Some common terms used with insurance:
(1) PCP - Primary Care Physician - you pre-select family physician . Your PCP must first provide you with a referral to a specialist or for any medical testing or treatment in order for you to receive your maximum benefits.
(2) Referral forms - forms provided and completed by your PCP that enable you to access specialty physicians or hospital services.
(3) Co-pays - a method of payment where both you and your insurance company are responsible for a portion of the medical bills. Your co-pay will be due at the time of service.
(4) Participating hospital/physician - Physicians and hospital that agree to see patients who are enrolled in a given health plan. Your insurance company or employer should provide a listing of this "provider-network" participating in your specific area.
(5) Insurance forms - it is your responsibility to complete and send forms to your insurance company. Failure to send correct forms will affect the payment of your bill.
(6) Pre-certified Admissions - the approval you or your physician receives from your insurance company to provide you with specified hospital and/or physician services.
(7) Deductibles - the amount of money you must pay each year before your insurance will pay.
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