Understanding The Benefits Of Private Health Insurance Plans
It is very easy to assume that if you hold a health insurance plan then your medical insurance provider will cover you for all eventualities. This is not however the case and not only will most health care plans exclude some forms of treatment but there is also very considerable variation between individual plans. Additionally, it is also often thought that once you have paid your premium then all of your medical bills are covered. Once again this is not the case and you will be expected, regardless of the plan you have, to pay at least a proportion of your medical costs.
Ideally you would like an individual or family health care plan to cover you for everything from preventative care through to major accidents and hospital care and everything in between. However, in reality the treatment which you are entitled to under your plan will almost certainly be limited and the plan will rarely meet all of your costs. As a result, it is extremely important that you read the small print of any plan before signing up for cover and that you understand exactly what you are and are not getting from your plan.
Traditionally indemnity (fee-for-service) health insurance plans have not covered preventative treatment, such as annual immunization and check-ups, although these are usually covered under HMO plans. This situation is however changing nowadays and more and more insurance companies are coming to the view that they can a considerable amount of money by concentrating more of their efforts on encouraging plan holders to stay healthy in the first place. As a result it is increasingly common to see preventative medicine covered by policies and some will even offer you discounts on the use of health club facilities and on programs which help you to quit smoking.
Most policies today will cover annual check-ups, annual eye checks, immunization, routine medical care, pre-natal care, well baby visits, urgent and emergency care and hospital care, including x-rays, blood tests and other laboratory work.
It is important to remember however that the mix of treatment which is covered will vary from plan to plan and so you must check any policy document carefully to see just what is insured. You must also read through the policy carefully to see what is specifically excluded.
The majority of health insurance plans will specifically list treatment which is excluded and this will typically include dental and vision care (other than routine annual eye checks) and a long alphabetical list of everything from acupuncture to weight loss treatments.
You will find that on a small number of plans dental and vision care is covered but, in general, health insurance plans in the United States do not provide this cover and separate dental and vision cover plans need to be arranged.
Another area for close attention is that of cover for the cost of prescription medication. As the cost of prescription drugs continues to rise a growing number of insurance companies are excluding cover for the cost of drugs from their policies. It is also becoming common for cover for the cost of prescription medication to be available through separate policies, as in the case of cover for both dental and vision care.
One final point to consider is that several states require specific provisions to be written into health care insurance plans sold to state residents. This is designed to protect residents against unscrupulous practices by the insurance companies and is generally of considerable benefit to plan holders. Such benefits are not transferable and benefits will be lost, or gained, as you move between states.
Health insurance plans can be a complex and far too many people assume that they are covered until they fall ill and suddenly discover that they are not covered, or that they are required to meet a substantial portion of the bill.
The secret to buying a health insurance plan is to read through any policy document before you take out cover and make sure that you are getting the cover that you need and want.
Cure provision: A provider contract clause which specifies a time period (usually 60--90 days) for a party that breaches the contract to remedy the problem and avoid termination of the contract.
Formulary: A listing of drugs, classified by therapeutic category or disease class, that are considered preferred therapy for a given managed population and that are to be used by an MCO's providers in prescribing medications.
National accounts: Large group accounts that have employees in more than one geographic area that are covered through a single national contract for health coverage. Contrast with large local groups.
Third party administrator (TPA): A company that provides administrative services to MCOs or self-funded health plans.
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