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Questions that are most asked about health insurance!

Topics:

What is a comprehensive plan and it's advantages?

Top A comprehensive plan provides coverage for most medical services using one reimbursement formula. In a pure comprehensive plan, a deductible must be met before reimbursement for any covered expenses begins, and coinsurance applies to all covered expenses until the maximum employee out-of-pocket expense limit is reached. Additional covered expenses are paid in full. Because employees share from the beginning in the cost of their medical expenses when they are incurred, a comprehensive plan encourages them to use more cost-effective health care. The patient is more likely to be cost-conscious and to seek out more cost-effective health care services and providers. What is included in the monthly service fee?

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What is an HMO?

A health maintenance organization (HMO) is an organization that contracts with or has physicians on staff and provides comprehensive health care to a population in exchange for premium dollars either paid by an employer group or individual. Typically only services rendered by providers within the network are covered however many variations of HMO plans are available. Many health maintenance organizations utilize a Primary Care Provider (PCP) that is either assigned or selected by the member. This PCP, also known as a gatekeeper, is responsible for monitoring and approving all care given to the member by other health care providers.

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What is a PPO?

A preferred provider organization (PPO) is an organization that contracts with a group of doctors, dentists, hospitals or other health care service providers to provide care at prearranged rates. Typically services rendered by providers within the contracted network are paid at a higher rate than those rendered by non-contracted providers.

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What health care costs are generally covered by comprehensive benefits?

Comprehensive health insurance plans vary by insurer, however they generally cover the same kinds of services.

These include:

Professional services of doctors of medicine and osteopathy and other recognized medical practitioners

Hospital charges for semiprivate room and board and other necessary services and supplies.

Surgical charges Services of registered nurses and, in some cases, licensed practical nurses.

Home health care

Physiotherapy Anesthetics and their administration X-rays and other diagnostic laboratory procedures X-ray or radium treatment

Oxygen and other gases and their administration Blood transfusions, including the cost of bloom when charged

Drugs and medicines requiring a prescription

Specified ambulance services

Rental of durable mechanical equipment required for therapeutic use Artificial limbs and other prosthetic appliances, except replacement of such appliances Casts, splints, trusses, braces and crutches.

Rental of a wheelchair or hospital-type bed.

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Are prescription drugs covered?

Generally, only prescription drugs that are for treatment of an illness or injury are covered. Many prescription drug programs impose coinsurance and co-pays. Many plans do not cover contraceptive prescription drugs, for example, or nicotine chewing gum prescribed for smokers who are trying to quit. Many pharmacy benefit plans have their own formulary (list of drugs) they approve for their members. Drugs outside the formulary may not be reimbursed or reimbursed at a very low rate.

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What is Medicare?

Medicare is a federal government hospital expense and medical expense insurance plan primarily for elderly and disabled persons.

Medicare Part A - The part of Medicare that provides basic hospital insurance coverage automatically for most eligible persons.

Medicare Part B - A voluntary program that is part of Medicare and provides benefits to cover the costs of physicians' services.

Medicare Part C - The part of Medicare that allows independent entities, such as commercial Managed Care entities, to offer health plans to Medicare beneficiaries.

Medicare+ Choice Medicare Part D - A voluntary program that is part of Medicare and provides benefits to cover prescription drugs.

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What is Flexible Spending Account?

Flexible Spending Accounts are accounts typically funded on a pre-tax basis through employee salary reductions arrangement. Any and all amounts in the account unused as of the end of the year must be forfeited. This is known as the use it or lose it rule. Flexible Spending Accounts are typically an employer offered health reimbursement arrangement also called a cafeteria plan. 

How it works...

An employee contributes a percentage of their pretax salary, up to the limit the plan allows. These dollars can then be used to pay for qualifying expenses, including medical costs that aren't covered by your health insurance, childcare, and care for your elderly or disabled dependents.

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What is considered a preexisting condition?

A pre-existing condition is an active condition that has been treated within the last year to five years, depending on the condition. If you already have prior insurance and wish to change then the pre-existing condition rule does not apply.

If you are without insurance then you are either put on a waiting period or the company will exclude any type of coverage for that condition. Unless, your going on group health insurance,  Depending on what state you live in will determine what rules apply; however, most insurance companies have to take you on their plan.


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