How Do I Choose A Quality Individual Health Insurance Plan?

Choosing the right individual health insurance plan is harder than it ever was. The choices can be very confusing. There is no one "best" plan, as people have different wants and needs.  Some plans will better suit you and your family's health insurance needs than others. Do you want a doctor's office co-pay? Do you need maternity coverage? What is the most you can pay if you are hospitalized? Plans can differ in how much you have to pay (premiums) and what services they include. Although no plan will include all the services associated with your medical care, some plans will include more than others.

Plans change from year to year and premiums for new enrollees change from month to month, so you should carefully consider each plan, using the questions outlined on this website. If you currently have an individual health insurance plan, you should start with your declaration of benefits section of your policy. This section will tell you what is covered under the plan and what the limits and exclusions are. You can also call your health insurance Company or current agent directly to ask questions.

Health insurance plans can be either traditional fee-for-service (indemnity) or managed care. The major differences concern choice of providers, out-of-pocket costs for covered services, and how bills are paid.

 Usually, fee for service plans (indemnity) offer a broader choice of health care providers including specialists, hospitals, and other health care providers. These are often referred to as any doctor or any hospital plans. Fee for service health insurance plans  (indemnity) pay their share of the costs of a service only after they receive a bill.  You or they send the bill to the insurance company, which pays part of it. Usually, you have a deductible such as $500 to pay each year before the insurer starts to pay for anything. Once you met the deductible, most indemnity health insurance plans pay a percentage (usually 80/20) of what they consider the "Usual and Reasonable Customary" charge for covered services. The insurer generally pays 80% and you pay the other 20% known as coinsurance. If the provider charges more than the Usual and Customary rates, you will have to pay both the coinsurance and the difference.  The plan will pay for charges for medical tests and prescriptions as well as from doctors and hospitals. It may not pay for some preventive care, like checkups.

  Managed care plans have agreements with certain doctors, hospitals, and health care providers to give a range of services to plan members at reduced cost. You will have less paperwork and lower out-of-pocket costs if you select a managed care type plan. There are basically three types of managed care plans: PPOs, HMOs, and POS plans.

Preferred Provider Organization (PPO) A PPO has made arrangements with doctors, hospitals, and other providers of care who have agreed to accept lower fees from the insurer for their services. In addition doctors making referrals to specialists, plan members can refer themselves to other doctors or specialists, including ones outside the plan.

If you go to a doctor within the PPO network, you may pay a copayment (a set amount you pay for doctors visits such as  $30 for a doctor or $15 for a generic prescription). Your coinsurance will be based on lower charges for PPO members.

If you choose to go to a doctor or hospital outside the network, you will have to meet the deductible and pay coinsurance based on higher charges. In addition, you may have to pay the difference between what the provider charges and what the plan will pay. You also may be penalized an additional 20% on your coinsurance. It is very important with a PPO to make sure the doctors and hospitals you go to are in their network.

Health Maintenance Organization (HMO) HMOs are the oldest form of managed care plan. HMOs offer an individual or family health insurance benefits such as doctors visits and preventative care, for a set monthly fee. There are many kinds of HMOs. If doctors are employees of the health plan and you visit them at central medical offices or clinics, it is a staff or group model HMO. Other HMOs contract with physician groups or individual doctors who have private offices. These are called individual practice associations (IPAs) or networks. HMOs will give you a list of doctors from which to choose a primary care doctor. This doctor coordinates your care, which means that generally you must contact him or her to be referred to a specialist. Your primary care doctor will serve as your regular doctor, managing your care and working with you to make most of the medical decisions about your care as a patient. In many plans, care by specialists is only paid for if your are referred by your primary care doctor. With some HMOs, you will pay nothing when you visit doctors. With other HMOs there may be a copayment, like $15 or $30 for various services. If you belong to an HMO, the plan only covers the cost of charges for doctors in that HMO. If you go outside the HMO, you will pay the bill. This is not the case with point-of-service plans.

 Point-of-Service (POS) Plan Many HMOs offer an indemnity-type option known as a POS plan. The primary care doctors in a POS plan usually make referrals to other providers in the plan. But in a POS plan, members can refer themselves outside the plan and still get some coverage.

If the doctor makes a referral out of the network, the plan pays all or most of the bill. If you refer yourself to a provider outside the network and the service is covered by the plan, you will have to pay coinsurance.

Some indemnity health insurance plans offer managed care-type options, and some managed care health insurance plans allow for the use of non-network doctors and hospitals (usually at a reduced rate of payment). It is very important for you to understand how your health insurance plan works. In considering any plan, you should try to figure out its total cost to you and your family, especially if someone in the family has a chronic or serious health condition.

Where Do I Get an Individual health Insurance plan for my family?

Individual Health Insurance Plan If you are a self employed individual or family and your company does not offer a group policy you will need to buy an individual health insurance plan. Individual and family health insurance plans cost more than group health insurance policies. You may want to talk to an insurance broker, who can tell you more about the indemnity and managed care plans that are available for individuals and families. A broker can also give you the health insurance rates and plan designs of several health insurance companies all at once. This will save you valuable time and effort and allow you to compare the best health insurance plans side by side to see which one will best meet your family's wants and needs. Signa Health will be happy to help you sort through the maze of health insurance plans. For a free quote you can call 1 877 433-3026 and talk to one of our trained specialist or you can check out health insurance plan rates from several major health insurance carriers online here at signahealthinc.com.

Pre-Existing Conditions A pre-existing condition is a medical condition diagnosed or treated before joining a new plan. In the past, health care given for a pre-existing condition often has not been covered for someone who joins a new plan until after a waiting period (usually 12 months). However, a new law called the Health Insurance Portability and Accountability Act changes the rules. Under the law, most of which went into  effect on July 1, 1997, a pre-existing condition will be covered without a waiting period when you join a new group plan if you have been insured the previous 12 months. This means that if you remain insured for 12 months or more, you will be able to go from one job to another, and your pre-existing condition will be covered without additional waiting periods even if you have a chronic illness. If you are in a individual health insurance plan or going into an individual health insurance plan then you will be required to wait the period of time for the pre-existing conditions to be covered. The individual carriers may also rate (charge you an extra premium)due to a condition, rider (put a clause on the health insurance policy that states it will not cover that condition) or even decline an individual (not offer health insurance). If you have a pre-existing condition and have not been insured the previous 12 months before joining a new plan, the longest you will have to wait before you are covered for that condition is 12 months.

 What Health Plan Benefits Are Offered?                                                                                                         The best plan for someone else may not be the best plan for you. For each plan you are considering, find out how it handles:

• Physical exams and health screenings.
• Care by specialists.
• Hospitalization and emergency care.
• Prescription drugs.

Some plans offer members health education and preventive care, but services differ. Ask questions such as:

• What preventive care is offered, such as shots for children?
• What health screenings are given, such as breast exams and Pap smears for women and PSA tests for men.
• Does the plan help people who want to quit smoking or lose weight? 

 What are my needs and wants in a individual health insurance plan? In choosing a plan, you have to decide what is most important to you. All plans have tradeoffs. Ask yourself these questions:

• What do I want my health plan to cover?
• What Doctors and hospitals do I want my family to use?
• Do I want to be able to refer myself to a doctor?
• Are the doctors and hospitals close to me?
• Do I want to pay extra to have a doctors copay and will I really use it enough to offset the extra cost?
• How much am I willing to spend on premiums?
• How much do I want to pay if one of my family is hospitalized?
• Do I want to pay extra for maternity coverage and do I need it?
• Is it a health insurance company I am comfortable with?

 How Do I Compare Health Plans?

After you review what benefits are available and decide what is important to you, you can compare plans. Many things should be considered. These include services offered, choice of providers, location, and costs. The quality of care is also a factor to think about.

Is there a good match between what is provided and what you need?

Find out what types of care or services the plan won't pay for. These usually are called exclusions.

Are your doctors and hospitals part of the plan? Do you need to choose a primary care doctor? If you want to see a specialist, can you refer yourself or must your primary care doctor refer you? Do you need approval from the plan before going into the hospital or getting specialty care?

Location

Where will you go for care? Are these places near where you work or live? How does the plan handle care when you are away from home?

Costs

No health insurance plan will cover every expense. To get a true idea of what your costs will be under each plan, you need to look at how much you will pay for your premium and other costs.

• Are there deductibles you must pay before the insurance begins to help cover your costs?
• After you have met your deductible, what part of your costs are paid by the plan?
• Does this amount vary by the type of service, doctor, or health facility used?
• Are there copayments you must pay for certain services, such as doctor visits?
• If you use doctors outside a plan's network, how much more will you pay to get care?
• If a plan does not cover certain services or care that you think you will need, how much will you have to pay?
• Are there any limits to how much you must pay in case of major illness?
• Is there a limit on how much the plan will pay for your care in a year or over a lifetime? A single hospital stay for a serious condition could cost hundreds of thousands of dollars.

You can't know in advance what your health care needs for the coming year will be. But you can guess what services you and your family might need. Figure out what the total costs to your family would be for these services under each plan.

How Do I Find Out About Quality?

Quality is hard to measure, but more and more information is becoming available. There are certain things you can look for and questions you can ask. Whatever kind of plan you are considering, you can check out individual doctors and hospitals. For doctors, see

Many managed care plans are regulated by Federal and State agencies. Indemnity plans are regulated by State insurance commissions. Your State Department of Health or insurance commission can tell you about any plan you are interested in.

Also keep any eye out for magazine articles that rate health plans.

Finally, you can see how AM Best rates the health insurance plan.

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