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Questions to Ask About Health Insurance Plans in the U.S.

Health Insurance Guide

Health Insurance Plan HMO PPO Services Coverage Provider Premium Deductible Policy Fee-for-Service

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Questions to Ask About Fee-for-Service Health Insurance Plans

  • How much is the monthly health insurance premium? What will your total cost be each year? There are individual rates and family rates.

  • What does the health insurance policy cover? Does it cover prescription drugs, out-of-hospital care, or home care? Are there limits on the amount or the number of days the health insurance provider will pay for these services? The best fee-for-service health insurance plans cover a broad range of health care services.

  • Are you currently being treated for a medical condition that may not be covered under your new health insurance plan? Are there limitations or a waiting period involved in the health insurance coverage?

  • What is the health insurance deductible? Often, you can lower your monthly health insurance premium by buying a health insurance policy with a higher yearly deductible amount.

  • What is the coinsurance rate? What percent of your bills for allowable services will you have to pay?

  • What is the maximum you would pay out-of-pocket per year? How much would it cost you directly before the health insurance company would pay everything else?

  • Is there a lifetime maximum cap the health insurance provider will pay? The cap is an amount after which the health insurance company will not pay anymore. This is important to know if you or someone in your family has an illness that requires expensive treatments.

Questions to Ask About HMO Health Plans

  • Are there many doctors to choose from in the HMO plan? Do you select from a list of contract physicians or from the available staff of a group practice? Which doctors are accepting new patients? How hard is it to change doctors if you decide you want someone else? How are referrals to specialists handled?

  • Is it easy to get appointments? How far in advance must routine visits be scheduled? What arrangements does the HMO have for handling emergency care?

  • Does the HMO offer the health care services you want? What preventive services are provided? Are there limits on medical tests, surgery, mental health care, home care, or other support offered? What if you need a special service not provided by the HMO?

  • What is the service area of the HMO? Where are the facilities located in your community that serve HMO members? How convenient to your home and workplace are the doctors, hospitals, and emergency care centers that make up the HMO network? What happens if you or a family member are out of town and need medical treatment?

  • What will the HMO health insurance plan cost? What is the yearly total for monthly fees? In addition, are there co-payments for office visits, emergency care, prescribed drugs, or other services? How much are they?

Questions to Ask About PPO Health Plans

  • Are there many doctors to choose from in the PPO health insurance plan? Who are the doctors in the PPO network? Where are they located? Which ones are accepting new patients? How are referrals to specialists handled?

  • What hospitals are available through the PPO? Where is the nearest hospital in the PPO network? What arrangements does the PPO have for handling emergency care?

  • What health care services are covered by the PPO plan? What preventive services are offered? Are there limits on medical tests, out-of-hospital care, mental health care, prescription drugs, or other services that are important to you?

  • What will the PPO health insurance plan cost? How much is the premium? Is there a per-visit cost for seeing PPO doctors or other types of co-payments for services? What is the difference in cost between using doctors in the PPO network and those outside it? What is the deductible and coinsurance rate for care outside of the PPO? Is there a limit to the maximum you would pay out of pocket?
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