Purchasing Health Care Coverage

Purchasing Health Care Coverage

There are basically two forms of coverage: traditional and managed care. Under traditional coverage the provider will bill you and you have to get reimbursed on the covered amount or will submit the claim and bill you for the amount not covered by the insurer. Managed care controls the delivery and financing of the system. While this generally is cheaper, it does limit your choices of doctors and providers. For many of the services, such as doctor visits and prescriptions, you will be charged a pre-set copayment.

There are a variety of managed care plans including Health Maintenance Organizations, Exclusive Provider Organizations, and Preferred Provider Organizations. The differing plans offer differing restrictions on how and where you can seek care and who can provide it. An agent can explain the differences.

Traditional care includes basic medical insurance and major medical insurance. Under basic medical insurance the hospitalization portion usually covers some of your room, board and services such as lab tests, X-rays and operating room use. The medical/surgical insurance pays for a portion of surgical related expenses delivered either in the hospital or doctor’s office. It may also pay for doctor visits for hospital care other than surgery. There are differing reimbursement schedules and benefits from plan to plan. Make sure to carefully compare these benefits along with premium rates to make sure you are getting the best plan. Your agent can help you compare.

Major medical insurance plans cover expensive hospitalization, injury or ongoing illness costs. It also may cover pharmaceutical costs and doctor visits. Group health plans generally are major medical plans. Major medical covers a higher percentage and a longer list of benefits than basic plans. Generally they pay 80% of the cost in excess of the deductible and this often is based on a fee schedule. Some plans will include maximum out-of-pocket limits on the amount of coinsurance you can be charged.

Group plans are often offered by your employer and cover several people or groups. Large group plans cover employer groups of over 50 employees and are often self-administered (see below). Small group plans cover one (eligible self-employed) to 50 eligible employees. Individual plans (one person or family members under one policy) can be requested if you lack employer based coverage or as a supplement to those polices.

Out-of-State Association coverage can be sold to members who are Florida residents but must be licensed by the state. However, the coverage may be governed by the laws of another state. This means the forms and rates charged may not be approved by the state and the mandates and protections required under Florida law may not be included.

Single employer plans that are self administered to some degree are regulated under the federal Employee Retirement Income Security Act (ERISA). These are not regulated or guaranteed by the state. Often bogus insurance plans that require state licensure will market themselves as ERISA plans and consumers have been severely harmed both financially and physically. Always make sure any insurance plan and agent are authorized to do business in the state by calling the Department of Financial Services at 800-342-2762 or click here.

There are numerous other health policies. These include supplemental policies that complement basic insurance policies; disability income insurance which pays you income for specific periods in which you suffer an illness or injuries that prevents you from being able to work; long-term care insurance which provides medical, personal or social services in the event you suffer long-term illness, injury or impairment; and nursing home care insurance that covers one or a variety of levels of nursing home care in Florida.

Finding an insurance agent who is a member of the Florida Association of Insurance and Financial Advisors is very easy. Click here to find one in your area:http://www.naifa.org/consumer/advisor.cfm