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Health Insurance

You thought finding an apartment and moving was difficult? Choosing appropriate health insurance in the United States can be one of the most bewildering and time-consuming processes you will ever undertake. To help you make sense of all the options and terms, we have prepared this short guide to explain the system and provide links to helpful sources.

GETTING STARTED

 

 

Option 1: Health Maintenance Organizations (HMOs)

 

An HMO is a prepaid health plan with an insurer that directly contracts with or employs its group of doctors, hospitals, specialists, emergency care, etc. Because they encompass your entire range of care, HMOs also support preventive procedures such as checkups and prenatal care to keep diseases from becoming more serious. HMOs will generally assign to you or allow you to designate one doctor as your primary care provider. Referrals from this doctor are then needed to receive appointments with specialists.

 

You pay: A monthly premium, co-payments for each office visit and most services.
Pros: Total medical costs tend to be lower and more predictable. You do not need to fill out claim forms for every visit, just present your HMO card.
Cons: Your choice of doctors and institutions is limited to the providers working with your particular HMO (with exceptions for emergencies or lack of care options). You also may end up waiting longer for an appointment than those with fee-for-service plans.

 

 

See also: Point-of-Service Plans (POS)

 

Offered under many HMOs, these plans allow patients or their doctors to make referrals to doctors outside of the HMO network. Those referring themselves receive some coverage, while those who are referred outside of the network by their doctors will receive complete or majority coverage.

 

 

Option 2: Fee-for-Service Plans

 

This plan allows you to choose any doctor or hospital anywhere in the country. The insurance company has no established list of doctors, and pays the fees for your services after you fill out forms and submit them. Coverage comes in two forms: “basic” and “major medical”. Basic coverage pays for only some hospital services, supplies, and surgeries. Major medical will in turn cover the cost of long-term, serious illnesses. It is recommended to get comprehensive coverage, i.e. both basic and major medical.
You pay: A monthly premium. A deductible each year per member of your family (perhaps $250) must be paid (only towards services covered under your plan) before the plan kicks in. After this happens, you pay a certain percentage of the bill (usually around 20%), with the insurance company picking up the rest. This is referred to as co-insurance. Most plans also have a cap on the amount you will have to pay for medical bills in one year, ensuring you never have to pay for more than anywhere to $1,000 to $5,000, depending on your plan and not including the monthly premium.
Pros: Full freedom of doctors and institutions. No need for referrals to see specialists.
Cons: You retain responsibility to keep track of all your medical expenses and save your receipts for medicines and visits. Preventive care such as child immunizations may not be covered by all plans.

 

 

Option 3: Preferred Provider Organizations (PPO)

 

This option is a combination of HMOs and fee-for-service plans. Just as in an HMO, you have a limited number of doctors and institutions to choose from (your “preferred providers”), with whom most of your bills will be covered. You follow the HMO procedure, submitting your HMO card and paying a small co-payment.
The twist is that with a PPO, you can visit doctors outside of the plan’s base and still receive some coverage, although you will have to fill out claims forms and pay a larger portion of the bill than with a true fee-for-service plan.
Pros: Allows you to keep a favorite doctor, even if they are not considered a preferred provider. The benefits of HMOs, with the additional freedom of fee-for-service plans.
Cons: More expensive.

 

IMPORTANT QUESTIONS

 

Once you understand these basics, research and find the plan that best fits your needs. Here are a number of things to keep in mind:
What is most important to you? Unlimited choice of doctors and hospitals, price, comprehensive coverage for all possibilities, paperwork loads, direct access to specialists?
What benefits are offered? Preventive care, child-immunization, prescription drugs, alcohol and drug abuse treatment, home care?
What are the costs? Deductibles, co-payments, penalties for using non-network doctors, limits to the amount you or your insurer will pay?
How important is location? Are the in-network doctors and institutions close by? What happens when you need care away from home?

 

USEFUL TERMS AND FURTHER INFORMATION

 

Coinsurance - The amount, usually a percentage, that one is required to pay in a fee-for-service plan after you meeting the deductible. The health insurance might cover 80 percent, leaving you to pay 20 percent.
Co-payment - A flat fee covering medical services and hospital visits. The patient pays a low amount for each service or visit, with the health insurance company picking up the rest.
Covered expenses – Those medical services an insurer will pay for. Some plans do not cover prescription drugs, while others do not cover many types of mental or chiropractic health care, for example. This information may be found in the health insurance policy.
Customary fee – Many insurance plans take into consideration the average fees charged by area doctors for a service or procedure, and refuse to pay more than this amount. Therefore, you need to be willing to pay the difference, or else shop around for a cheaper price or ensure that your doctor will accept your insurance as full payment.
Deductible – the amount you must pay each year towards valid health expenses before your health insurance begins to pay.
Exclusions – Certain benefits, practices, or circumstances for which the health insurance company will not pay.
Non-cancelable policy – Guarantees that as long as you pay the premium, you will receive health insurance. This guards against the revoking of a policy upon the occurrence of serious illness.
Premium – The amount paid by you or your employer monthly for health insurance policy coverage.

Viktoriya Safronova - Real Estate Agent, New York
Viktoriya Safronova
Senior International Real Estate Advisor
Licensed Real Estate Salesperson
Evans relocation


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