How to Determine what Health Plan Option is best

Selecting The Health Insurance That Fits Your Needs

Selecting health insurance is not all about rates and quotes but about what fits your family and your budget. People like myself who have been in the insurance business for over fifteen years have seen many changes. Although insurance sometimes gets a bad beat around the office cooler, I can tell you the changes have been for the good.

Back in 1970 you worked for a company and they dictated what kind of policy you would have. And providers did not file insurance for you. There was no comparing rates or choosing policies. Most policies were based on a 80/20 split and the patient was responsible for turning the bill into their company for reimbursement. The doctor had to be paid right then, or least a payment had to be made. Many people put off going to the doctor for this very reason.

This is not true today. Companies and health care providers are more in tune with helping people stay healthy and in promoting preventative care. Insurance companies have finally learned that paying for preventative care can save them money in the long run. Today we have POS (Point of Service) contracts, PPO (Preferred Provider Organization), and HMO(Health Managed Organization) contracts.

Some companies even take it a little further and offer all three of these types of insurance and let you pick which one fits your needs the best. Selecting the health insurance that you need is not that complicated once you understand a little about each type of policy.

How Do You Know Which Is Best For Your Family?

Whether you are picking an individual policy or a group policy from work, there are things to consider before making your selection.

1.Finances for premiums or the amount of the office co-pay can be an issue for some families. What you need to remember is that most policies have a deductible max for families and so every member of your family may not have to reach their deductible before the insurance will pay. For example, your policy has a $200.00 deductible per person but a $600.00 max. So if you are a family of four, you would only have to meet $600.00, not $800.00.
2.How much your family goes to the doctor is a big factor. If your family is very healthy and only a few trips to the doctor a year are made, you can have a policy with lower premiums and higher deductibles and out of pocket expense. Why pay for high premiums when you don’t go to the doctor?
3.HMO policies look good from a money out of pocket standpoint but there are sometimes problems with the doctors you want not being in the HMO network. These HMO networks are smaller than the PPO and POS.
4.POS policies have a good network of providers but everyone must have a primary care physician who oversees their health care. This means in order to get network benefits, the PCP must refer you to a specialist in the network. If you just pick a doctor and go on your own, you will not received network benefits.
5.PPO polices are the best to me. You still have the same large network of providers, however you can see any doctor you want in the network and get network benefits. No referral is needed from anyone. Just remember if the doctor you pick is not in the network, you will received out of network benefits. The amount of deductible is higher and the percentage paid is much less in those cases.

How Do I Know If My Doctor Is In My Network?

Knowing how to make sure the doctor you have selected is part of your network is very important. With so many good doctors today there is no need to pay high premiums then turn around and get less benefits because you didn’t do your homework.

1.Ask the doctor if he takes your insurance and is a part of your network.
2.Call the customer service number on your insurance card and ask about the doctor.
3.Most insurance companies have a directory on line for the doctors in their network and you can see if they are on the list.

Are You Checking Your Completed Claims Summary of Benefits?

As an auditor of claims for a major insurance company I can tell you that mistakes on your claim can and do happen. Always check your EOB(explanation of benefits) when you get it in the mail. Too many people trust the insurance company to get it right. Most of the time they do, but just like in any business, people make mistakes.

Here is how you can check your benefits. You know if the doctor you saw is in the network or not and when you picked your plan you should have learned what benefits you have for office visits, lab work and so on. Keep your book near you for a handy reference.

If you know you have a $20.00 copay, then you should not owe anything else. If you went for lab work and you know your policy pays 80% of the allowed amount, then that is what you compute. Every doctor will bill an amount but the insurance company tells them what the “allowed amount” is. The payment for the doctor is figured from the allowed amount. So if the doctor bills $100.00 and the insurance company says the allowed amount is $80.00 then they will be paid from that.

Keep a calculator by your benefits booklet and you will never pay more than you have to. If by some chance you do find a mistake, call the customer service number on the back of your insurance card and they will adjust the claim for you once they see what has happened.

One final piece of information I would like to give is about the insurance companies. Every state has an insurance board commission that looks into any bad conduct or misrepresentations. Don’t hesitate to use them if you need too, but please go through your benefits coordinator and customer service numbers first and try to resolve your situation together.