Choosing a Health Insurance Plan

Many people that come to me for advice are confused by health insurance and do not know how to choose a health insurance plan for themselves.  Typically the person has been employed and the employer chose the health insurance for his employees.  When a person has to make the choice himself, it seems like a big decision that could have bad consequences if he chooses the wrong plan.  Following are three points to keep in mind when you choose a plan.

1.       What is your budget?  Most health insurance decisions are made by the monthly premium a person thinks he can afford.  If you do not have insurance, how much will it cost? 

a.       I received a call one day from a man who said that he needed insurance because he just spent $25,000 on an emergency room visit and now he needs surgery.  Unfortunately, that’s like asking for car insurance after a car accident.

2.       How often do you use medical services?  What prescriptions, if any do you use?  Every health insurance plan has limitations on different services. 

a.       For instance many plans now have a limit on the number of doctor visits per year that are covered prior to meeting the deductible.  Reviewing your use of medical services the prior year can help you decide the type of plan to purchase.  After all, you do not want to pay for services that you really do not need.

3.       Finally, how much can you afford if the worst case scenario happened and you had an accident or a serious illness?  Health insurance plans have a “Maximum Out of Pocket” limit per year.  That means that once you spend the “Maximum Out of Pocket” amount, the insurance company will pay the expenses for the remainder of that calendar year. 

a.       That happened to my husband this year when he had surgery.  He reached his “Maximum Out of Pocket” limit.  Even with this limitation, we discovered that there are some expenses that we were responsible to continue to pay.  Therefore it is a good idea to understand your policy so you do not get surprised.

In conclusion, you can make the best decision about the health insurance plan by looking at your budget, but also look at the consequences of not having insurance.  Then understand what benefits you need for yourself and for your family.  And finally look at how much you can afford if the worst case scenario happened and you had major medical expenses.  How much can you afford to pay for a monthly premium?  How much can you afford to pay for a deductible before your plan begins paying expenses? And finally how much can you afford to pay for a major medical expense in a given year?  Having answers to these questions can lead you to a good decision about the health insurance you need.

Health Reform - Preventive versus Diagnostic Services

One of the positive aspects of the Health Reform bill is the $0 Preventive Services benefit offered in Non-grandfathered plans (new plans beginning on or after September 23, 2010).  If you are on a Non-grandfathered plan, a selection of preventive services must be covered without your having to pay a copayment or coinsurance or meet your deductible, when these services are delivered by a network provider.  But how do you know if the service or test is considered Preventive or Diagnostic?

The easy and simple way to understand the general difference between preventive and diagnostic services is demonstrated by Mammography and Colonoscopy.  For instance, if you receive your routine Mammogram according to schedule, it is considered a preventive exam.  However if you find a lump and request a mammogram, then it is considered a diagnostic test subject to the coinsurance or copay your benefits plan offers.  Similarly a colonoscopy is considered a preventive test when there are no symptoms or concerns and is performed to validate that the patient/member is healthy.  If a problem has been brought to the attention of the doctor, then it is no longer considered preventive. 

The Health Reform bill is working under interim rules; so many aspects have not been clearly defined.  And insurance companies and/or doctors and facilities interpret the law differently, so many tests may not fall under the easy definition that a colonoscopy or a mammogram does.  My best advice is to ask questions before the test and/or read your Explanation of Benefits (sometimes called EOB) carefully.  If you don’t agree with your invoice or have questions about your medical bill, call the insurance company and then call the billing service where the procedure was performed to understand what and why you are charged.  Now is the time to become an informed consumer in the medical field as well in other areas. 

WA Open Enrollment for Children under 19

Due to the new Health Reform Bill, insurance companies can no longer deny health insurance coverage to children under 19 who have pre-existing conditions (for example, a current or ongoing medical condition). However, there are specific enrollment periods in which children must apply for coverage. The next Washington state enrollment period begins March 15, 2011 and ends April 30, 2011. If children miss this enrollment period, the next opportunity to get coverage (except for specific situations) will be September 15, through October 31^st. This also includes families who have children under 19 who are looking for an individual insurance plan. This rule does not apply to children/students over 19.

Please tell anyone you know who wants to get either child only or family individual insurance coverage to begin shopping for health insurance now. 

Marsha Lewis

marsha@healthguidepost.com

360-606-2616

www.healthguidepost.com