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Understanding and Choosing a Health Insurance Plan

Health Insurance Guide

Health Insurance Plans Health Care Services Costs

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Understanding health insurance plans can be very complicated. There are many health insurance plans available, and deciding which one is best for you is not easy.

Invariably, you will have to compromise in some areas. Whether it is cost, variety of health services covered or access to the doctors of your choice, you probably will not get the perfect health insurance plan. The following guidelines will help you to understand your options.

What Is Most Important to You in a Health Insurance Plan?

In choosing a health insurance plan, you have to decide what is most important to you. All health plans have tradeoffs. Ask yourself these questions:

  • How comprehensive do you want coverage of health care services to be?
  • How do you feel about limits on your choice of doctors or hospitals?
  • How do you feel about a primary care doctor referring you to specialists for additional health care?
  • How convenient does your health care need to be?
  • How important is the cost of health services?
  • How much are you willing to spend on health insurance premiums and other health care costs?
  • How do you feel about keeping receipts and filing health insurance claims?

You might also want to think about whether the services that a health insurance plan offers meet your needs. Call the health insurance plan for details about coverage if you have questions. Consider:

  • Life changes you may be thinking about, such as starting a family or retiring.
  • Chronic health conditions or disabilities that you or family members have.
  • If you or anyone in your family will need health care for the elderly.
  • Health care for family members who travel a lot, attend college, or spend time at two homes.

What Health Insurance Plan Benefits Are Offered?

Most health insurance plans provide basic medical coverage, but the details are what count. The best health insurance plan for someone else may not be the best plan for you. For each health insurance plan you are considering, find out how it handles the following:

  • Physical examinations and health screenings.
  • Health care by specialists.
  • Hospitalization and emergency care.
  • Prescription drugs.
  • Vision care.
  • Dental services.
  • Care and counseling for mental health.
  • Services for drug and alcohol abuse.
  • Obstetrical-gynecological care and family planning services.
  • Ongoing care for chronic (long-term) diseases, conditions, or disabilities.
  • Physical therapy and other rehabilitative care.
  • Home health, nursing home, and hospice care.
  • Chiropractic or alternative health care, such as acupuncture.
  • Experimental treatments.
  • What preventive care is offered, such as shots for children?
  • What health screenings are given, such as breast exams and Pap smears for women?

What Are the Health Insurance Costs?

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

  • Are there deductibles you must pay before the health insurance begins to help cover your costs?
  • After you have met your health insurance deductible, what part of your health costs are paid by the plan?
  • Does this amount vary by the type of service, doctor, or health facility used?
  • Are there co-payments you must pay for certain health 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 health insurance plan does not cover certain health 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 health insurance 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 cannot know in advance what your health care needs for the coming year will be. But you can guess what health services you and your family might need. Figure out what the total costs to your family would be for these services under each health insurance plan.

Location of Health Care Services

  • 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?

Limitations on Health Care Services

Look at the services offered by each health insurance plan.

  • What services are limited or not covered?
  • Is there a good match between what is provided and what you think you will need? For example, if you have a chronic disease, is there a special program for that illness?
  • Will the plan provide the medicines and equipment you may need?

Find out what types of care or services the plan will not pay for. These are usually called exclusions.

Few indemnity and managed care plans cover treatments that are experimental. Ask how the plan decides what is or is not experimental. Find out what you can do if you disagree with a plan's decision on medical care or coverage.

Compare Health Insurance 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.

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