| Before selecting a policy from an employer | | | | the no-deductible rule is an HMO that is |
| menu (or shopping for an individual policy), | | | | eligible for a health savings account.) There |
| you should be certain you understand the | | | | are usually no forms to fill out or bills to |
| terms used by the health insurance industry. | | | | keep track of. You are, however, quite |
| The meanings can vary slightly among | | | | limited in your choice of doctors, hospitals, |
| insurers, so if a number or explanation | | | | and other health-care providers. You commonly |
| doesn't match up with the following | | | | must get a referral from your primary-care |
| definitions, press the insurance provider for | | | | physician to see a specialist; if you don't, |
| more details; there may be costs or | | | | your treatment with the specialist is not |
| exceptions hidden in the differences in | | | | covered. Though HMOs were designed to control |
| jargon. | | | | costs, they have been the source of many |
| | | | consumer complaints. These complaints were |
| Coinsurance is the amount you must pay after | | | | often because of coverage limitations or the |
| your health plan's deductible has been met. | | | | fact that some doctors were compensated for |
| It's usually expressed as a percentage. For | | | | denying treatment or referrals to patients or |
| instance, you might have to pay 20 percent of | | | | punished for providing what was considered by |
| every bill until the total of your own | | | | the HMO to be excessive treatment, although |
| payments hits your out-of-pocket maximum. | | | | both problems have lessened in recent years. |
| | | | Because of their comprehensive, |
| Copayment is a flat fee you pay for | | | | deductible-free coverage, HMOs often compete |
| health-care services, regardless of how much | | | | with the most affordable health insurance |
| the doctor or hospital receives from your | | | | options. |
| insurance provider. Some plans, especially | | | | |
| HMOs and some PPOs, require a copayment, | | | | An HSA (health savings account) is a less |
| usually $10 to $30 for each office visit to a | | | | expensive, high-deductible policy linked to a |
| doctor and often higher copayments for | | | | tax-free savings account that can be used to |
| emergency care. | | | | pay medical bills before the policy's |
| | | | deducible is met. |
| Credit for prior coverage may be something | | | | |
| you need to prove -- normally with a letter | | | | Lifetime maximum is the maximum amount of |
| from your former insurer -- if you are | | | | covered expenses your insurance company will |
| switching employers or insurance plans and | | | | pay in your lifetime. Look for a policy with |
| need preexisting conditions to be covered | | | | a lifetime maximum of at least $3 million. |
| right away. This is especially important if | | | | |
| you are buying an individual policy, which | | | | Out-of-pocket maximum is the amount of |
| can have a waiting period for preexisting | | | | coinsurance you must pay yourself before an |
| conditions. | | | | insurance policy will pay 100 percent of your |
| | | | bills. It may or may not include the |
| A deductible is the amount you must pay for | | | | deductible. The term stop-loss is sometimes |
| your medical bills before your insurance | | | | used to refer to the point at which you have |
| kicks in. Usually the higher the deductible | | | | met your deductible and paid your |
| runs, the less expensive the policy is. | | | | out-of-pocket maximum. |
| | | | |
| EOB (explanation of benefits) is a statement | | | | A POS (point-of-service) plan is like a PPO |
| from your insurance company showing what it | | | | except that you need a referral from your |
| has paid and not paid for a claim. Some | | | | primary-care physician to see an |
| companies resist supplying duplicate EOBs, so | | | | out-of-network doctor, for which you may have |
| maintaining an organized file of your EOBs is | | | | to pay extra. Without the referral, you will |
| important if you need to challenge a bill. | | | | likely have to pay the entire bill for the |
| | | | out-of-network physician. |
| An EPO (exclusive provider organization) plan | | | | |
| allows you to use any doctor or hospital | | | | A PPO (preferred provider organization) plan |
| within the insurance provider's current | | | | is a cross between a fee-for-service plan and |
| network, without a referral. You have no | | | | an HMO. You can see any doctor you choose |
| coverage, however, outside the current | | | | without a referral, although if the physician |
| network even if your doctor used to be | | | | is outside the insurance plan's network you |
| included in the plan. There can be copayments | | | | will probably be reimbursed at a lower rate. |
| similar to those for HMO and PPO plans. | | | | For network doctors, you usually have only a |
| | | | copayment for office visits. There can be |
| A fee-for-service (indemnity) plan is the | | | | varying copayments -- as well as deductibles, |
| traditional kind of healthcare policy that | | | | coinsurance, and out-of-pocket maximums -- |
| allows you to go to any doctor or hospital | | | | depending on the policy. Most plans that are |
| you choose. Deductibles can range from | | | | eligible for use with a health savings |
| several hundred to several thousand dollars. | | | | account are PPOs with a high deductible |
| After you have paid bills totaling your | | | | tacked on. |
| deductible, the plan usually pays 80 percent | | | | |
| of all bills; you pay the other 20 percent up | | | | These terms, of course, aren't exclusive to |
| to an out-of-pocket maximum that generally | | | | individual policies. Many employers offer a |
| runs between $1,500 and $3,000. After you | | | | menu of plans for you to select from that |
| have reached the out-of-pocket maximum, the | | | | usually includes HMOs, PPOs, and traditional |
| policy pays 100 percent of your medical | | | | indemnity plans. Increasingly, companies are |
| expenses. In most states, fee-for-service is | | | | offering HSAs and dropping indemnity plans |
| the most expensive health insurance you can | | | | because they are so expensive. |
| buy. | | | | |
| | | | Reprinted from Health Care on Less Than You |
| An HMO (health maintenance organization) is | | | | Think: The New York Times Guide to Getting |
| essentially a prepaid health plan. For a | | | | Affordable Coverage by Fred Brock. Copyright |
| monthly premium, the HMO provides | | | | © 2006 Fred Brock. Published by Times |
| comprehensive care. You likely pay a | | | | Books; October 2006;$15.00US/$20.00CAN; |
| copayment for office visits, but most HMO | | | | 0-8050-7980-7. |
| plans have no deductibles. (The exception to | | | | |