Affordable Healthcare: Can It Happen To You?By Irina
========================================================== The author grants permission to publish this article, in its entirety, electronically or in print, as long as
bylines are included. A courtesy copy of your publication (or, at least, an e-mail notification) sent to irbonness@ureach.com will be appreciated. ==========================================================
Let's face it - an apple a day is no longer an adequate substitute for
professional healthcare services. And after
doctor leaves, someone has to reach for a wallet. Accept this undeniable fact of life and make necessary arrangements BEFORE you get into a car accident, suffer intolerable toothache, or become pregnant.
The cold reality of healthcare in this country is that you do not have any legal right to it. There are no state or federal laws mandating employer-paid or -subsidized health benefits. So if you (or your spouse) have a complete and reasonably priced health coverage through your employer - BE GRATEFUL... and find some better use for your time than reading this article. (I would still suggest saving it - just in case...)
For those who keep on reading, health insurance is available on an individual or group basis, but don't be fooled by
terms! INDIVIDUAL insurance usually covers A GROUP of people (entire family), and many GROUP health plans will cover "a group" of ONE. In both cases you are
only one paying (individually!) for
coverage. So, what's
difference? From a consumer's point of view,
big advantage of group health insurance plans over individual is that they can't turn you down because of health problems.
Of course,
ABILITY to get into a health insurance plan is one thing. The AFFORDABILITY is quite another! Let's begin with some basic terminology (or should we call it deceptive lingo?) used in
health insurance industry. Here are major plans with unique features to consider while making your choice:
HMO - Health Maintenance Organizations ============================================= The least expensive, but also
least flexible of all
health insurance plans. Advantage: - Low co-payments, minimal paperwork, and coverage for some preventive-care and health-improvement programs. Disadvantages: - You must choose a primary care physician, also known as a PCP. - HMO requires that you see only network doctors, or they won't pay. - You must get a referral from your PCP to see a specialist.
POS - Point Of Service plans ============================================= More flexible than HMOs, but they also require you to select a PCP. Advantages: - You may visit a doctor outside
network and still receive coverage; but substantially less than if you stayed within your network. - Offer more preventive care and well-being services, such as workshops on smoking cessation and discounts to health clubs. Disadvantages: - You must choose a PCP. - If you don't receive permission from your PCP, you're likely to wind up submitting
bills yourself and receiving only a nominal reimbursement - if any.
PPO - Preferred Provider Organizations ============================================= Give policyholders a financial incentive - reasonable co- payments (also called co-pays) - to stay within
group's network of practitioners. Advantages: - The standard co-payment is $10 for a routine office visit during regular hours. - You may go to any specialist without permission, as long as
doctor participates in
network. Disadvantages: - If you see an out-of-network doctor, you may have to pay
entire bill yourself, then submit it for reimbursement. - You may have to pay a deductible if you choose to go outside
network, or pay
difference between what network doctors charge vs. out-of-network doctor's charge.
FFS - Fee-For-Service plans, also called Traditional Indemnity ============================================= Offers flexibility in exchange for higher out-of-pocket expenses, more paperwork, and higher premiums. Advantages: - You may choose your own doctors and hospitals. - You may visit any specialist without getting permission from a primary care physician. Disadvantages: - There's a deductible (from $500 to $1,500) before
insurance company starts paying claims, and then doctors are reimbursed about 80 percent of
bill while you pick up
remaining 20 percent. - You may have to pay up front for medical services, then submit
bill for reimbursement. - FFS plans pay only for "reasonable and customary" medical expenses. If your doctor charges more than
average for your area, you will have to pay
difference.