Choosing A Health Plan
What should I consider when choosing a health insurance plan?
In choosing a health care plan, it's important to consider whether your plan will pay for you to see your doctor. Secondly, how they will pay your doctor. Do they pay in per capita amount where your doctor gets $30 a month, whether he or she sees you or not, and if you get a referral; that person gets penalized. You want to understand how your doctor is paid in this insurance situation. Most of us don't want to pay anything for our insurance. Most of us want a very small co-pay and most of us want no deductibles. Unfortunately, the best plans have larger deductibles and have larger co-pays. In my situation, I want my doctor and my kid's doctor to get paid as much as possible. I want as little going to the middleman or the insurance company, and usually that's achieved by higher deductibles and higher co-pays.
How much should cost matter when choosing health insurance?
One thing is cost, and you have to be able to live within your budget. It is much better to have health insurance than not. However, it's the one area if you can afford to spend the extra money, that you usually get the benefit. The concept of "you get what you pay for" is so important in health insurance. If you can afford a better plan, with a higher deductible, with a higher co-pace, it hurts every time you pay that, but if you have a tragedy, if you have a medical emergency, you're more likely to get care. Additionally, the more you're paying, the more likely you're able to get into your doctor's office; the more happy your doctor is to see you. Imagine if your doctor gets $30 a month and you need five visits in one month, how excited is that doctor going to be to see you? There's some real world factors that do deal with money. So, cheaper is not always better in health care.
What will a typical health care plan cover?
If you are in a standard health plan, they will usually always cover everything that you and I could probably pay out of pocket if we worked at it, such as physicals, regular visits, colds, and flu. A lot of health plans want to give you a car seat, they want to give you eyeglasses, they want to give you all of these things that we could all probably cover and save up enough for. Those are the ones to be most leery of because those are the ones that have to try to restrict all of the big ticket items as much as possible, because they're giving away so many of the trivial things. Generally, they're going to cover medically necessary care that you need that is not otherwise excluded in their insurance contract. Another important thing is to check the exclusions in your insurance contract to see what they are trying to tell you upfront that they won't cover.
What will a typical health care plan not cover?
Most insurance companies do not want to cover things that they believe are not medically necessary. That is one of the many definitional catch-phrases that can mean anything and gives them a lot of latitude to move. They will usually say whatever you need, and your doctor says you need, if it's expensive, is not medically necessary, there are cheaper alternatives, there are other ways to achieve it. So medically necessary is a very important term for anybody who is arguing to their insurance company, you have to always prove to them that your treatment is medically necessary, and they have many ways to define that. Generally, they don't like to pay for things that are deemed experimental. However it's almost impossible to define experimental, as in the practice of medicine we're always trying to improve every procedure. At university hospitals they're always doing something and if they're working on a new procedure to do an appendectomy, they will have you sign something called the Experimental Bill of Rights, because they want to publish and talk about how this new device is helping appendectomies. So there are always ways for them to try to take a very costly procedure, put it into one of their exclusions, generally under experimental, investigative, or under not medically necessary. Additionally, for anorexics and for people who have illnesses that might have a psychological component, although very medical in the harm they cause, they will always try to say it's psychological in nature, this is something that counselling can cure even though someone's heartbeat is gone and they actually don't have enough weight to exist. We see that in different crossovers that might have a psychological component.
Can my health insurance company change my policy?
There are procedures each state has for your insurance company to be able to change your policy. They have to give you a certain amount of notice, they have to still cover all medically necessary things, but they can go in and limit certain parts of your care if they give you appropriate notice, and that's an important facet to look at. Most regulations preclude them from taking away life saving surgery that they offered to you last year, but this year they're not doing it. So that is an important thing, but it is usually on non-life threatening items and it usually has to do with deductibles, co-pays, and other financing mechanisms.
Can my health insurance company cancel my policy?
Your health insurance company, under some circumstances, can cancel your policy. If you have lied on an enrolment application that you've never had cancer before and they prove that you've had cancer, there's legal ways for them to disenroll you. There has been a lot of graft exposed from health insurance companies where if you do discover cancer, they immediately deny you and want to overturn your policy based on the fact that they believe you may have misrepresented that. That's a good example of a bad-faith action that deserves, usually, some type of court filing to hold them accountable for that. Generally, if there's a material misrepresentation in your application, they can cancel you. Also, if they go bankrupt, they can obviously cancel you.
What are the pitfalls of a PPO plan?
One of the concerns most people have with a PPO is that there's generally a monthly cost to the insurance company, and then there's a co-pay, and in many PPOs there's also a deductible. Generally health insurance is not the one area you want to try to save the most money, and if you can look at it that you want your doctor to welcome you in the office, you want your doctor to be paid as much of that money as possible, otherwise it goes to some entity on Wall Street. It helps us to make that difficult financial decision, but you do not want to skimp on health care, and PPOs generally cost more. There's a deductible and there's usually a cap on the total amount of lifetime benefits, whereas with an HMO product there's usually less of a co-pay and there's no cap on lifetime benefits. That only really comes into play in rare circumstances for someone who's injured and needs 24-hour care, and it's a very rare circumstance. However, in those circumstances, not having a cap on your life care plan at two million can be helpful to be in an HMO, but they're rare.
What are the pitfalls of an HMO plan?
In HMO you are usually restricted in a network, and that means you must go to everybody in their own little pool. You can't step out of the pool and go to any other doctor unless you first get approval. Your choices are limited and you tend to sometimes not get the best doctors because the best doctor does not want to accept the minimal payment from an HMO system. The best doctors usually do not want HMO patients, so you are often limiting your ability to get the best medical care to the people that are willing to work for an HMO.
