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