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• Be Insurance Savvy!
Think about your health needs before you sign on for a specific
health insurance plan. The more you learn, the more easily you'll
be able to decide what fits your medical needs and budget.
- INFO FROM OTHERS - Talk to other
families and adults with disabilities about covered services and
out-of-pocket expenses . The office manager or billing clerk for
the doctor's office will know which plans cover which services.
- NEEDS vs WANTS - Prioritize your needs: Do you want to stay with your current doctors? Do you want reduced out-of-pocket costs? Do you want a particular treatment to be covered?
- KNOW ELIGIBILITY –Learn
about eligibility requirements for both private and public health
insurance programs financial, medical condition, physical and
mental functioning criteria.
- KNOW YOUR BENEFIT PLAN - Read
your policy to understand the benefits packages.
Many employers and health insurance companies now have the policy
benefit summary on line for your review. Look for descriptions
of age caps, student status, and adult dependent child coverage.
- WILLING TO ACCEPT - Keep in mind
no plan is perfect, and no plan covers everything. You can also
change your choice of plans during next year's Open Enrollment.
- DOCUMENTATION - Learn to provide adequate documentation to justify specialized services and customized medical equipment. More than a prescription is needed these days. Brief descriptions, test results, preventative cost savings estimates, and pictures are helpful.
- APPEALS - Understand appeals processes if services you think should be covered are not.
- KEY TEST- The Benefit Inquiry
Sometimes the Benefits Package doesn't fully describe what
is covered and what isn't, such as customized equipment or some
medical procedures. The absolute test to see if a service is covered
can happen after one is enrolled in a health plan. At this point,
a vendor can call on behalf of a health plan subscriber's request
for a service to assess what and if it will be covered
• Understanding Health Insurance Plans Options
Types of Insurance Plans
Insurance plans can be purchased through an employer, COBRA, self-employed business, individual purchase and State High-Risk Pool.
4 Types of Insurance Plans
- INDEMNITY INSURANCE: (also called Fee-For-Service)
- Traditional insurance coverage
- Pays for most of your health problems but not the total cost of services/products .
- Doesn't usually pay for preventive care like well visits and physical exams.
- You can see any doctor or hospital you want
- Monthly premium is usually higher than other types of health plans
- HMO: Health Maintenance Organization
- Covers most of your health care needs, including checkups, immunizations and hospitalization, for a small co-payment typically between $5 and $40.
- No claim forms
- Limited to only the doctors and hospitals affiliated in their plan.
- PPO: Preferred Provider Organization
- Covers many of your health care needs for a small per-visit fee if you choose from the list of "preferred providers."
- If you choose to see a doctor who's not on the list, but you'll pay more.
- Some PPOs do require claim forms.
- POS: Point of Service
Gives you two different choices each time you use health care services:
- LOWER COST - THEIR DOCTORS AND PRE-AUTHORIZATION
Use the plan just like an HMO for a nominal co-payment when choosing physicians who are on the list and for obtaining authorizations for certain services and referrals to specialists from your primary provider.
- HIGHER COST CHOICE OF DOCTOR.
Use your health plan just like an indemnity plan by choosing care from either a participating provider or a non-participating provider, without coordinating care through your primary care physician or health plan. You will pay a deductible and a percentage of your bill.
• Choosing a Health Insurance Plan
What you should look for. What you need to know before choosing one. And remember, if the plan you select is not as good as you expected, you can always change to another plan during annual open enrollment.
AGENCY FOR HEALTHCARE RESEARCH AND POLICY
Choosing and Using a Health Plan
www.ahcpr.gov/consumer/hlthpln1.htm
Choosing between health plans is not as easy as it once was. Although
there is no one "best" plan, there are some plans that
will be better than others for you and your family's health needs.
Plans differ, both in how much you have to pay and how easy it is
to get the services you need. Although no plan will pay for all
the costs associated with your medical care, some plans will cover
more than others. Almost all plans today have ways to reduce unnecessary
use of health care and keep down the costs of health care, too.
This may affect how easily you get the care you want, but
should not affect how easily you get the care you need.
AMERICAN ASSOCIATION OF HEALTH PLANS (AAHP)
www.aahp.org
The AAHP represents more than 1,000 HMOs, PPOs, UROs and other network
based plans. Site links to several health plans web sites then to
summaries of benefits.
AMERICAN ASSOCIATION FOR RETIRED PEOPLE
Health Insurance for Children: Information for Grandparents
www.aarp.org/confacts/grandparents/healthins.html
AARP- Census Bureau figures show that children in grandparent-headed households are much less likely than children in parent-headed families to have health insurance. Like all uninsured children, this means they are less likely to have a regular source of medical and dental care and are less likely to receive medical care from health care professionals specially trained to take care of children and are more likely to go to a hospital emergency room for treatment.
AMERICAN ASSOCIATION OF FAMILY PHYSICIANS
Understanding Your Insurance Coverage
familydoctor.org/handouts/733.html
Your health insurance policy is an agreement between you and your insurance company. The policy lists a package of medical benefits such as tests, drugs and treatment services. The insurance company agrees to cover the cost of certain benefits listed in your policy. These are called "covered services." Your policy also lists the kinds of services that are not covered by your insurance company. You have to pay for any uncovered medical care that you receive. Keep in mind that a medical necessity is not the same as a medical benefit. A medical necessity is something that your doctor has decided is necessary. A medical benefit is something that your insurance plan has agreed to cover. In some cases, your doctor might decide that you need medical care that is not covered by your insurance policy.
EMPLOYEE BENEFITS SECURITY ADMINISTRATION (EBSA)
elaws Health Benefits Advisor
www.dol.gov/elaws/ebsahealth.htm
An interactive Web site that will serve as a resource to help employees and their families make informed decisions about their health benefits when facing life and work changes. In addition to learning the specific requirements and rights under laws like the Consolidated Omnibus Budget Reconciliation Act (COBRA) and the Health Insurance Portability and Accountability Act (HIPAA), the Web site provides information about the rights and responsibilities of employees and their families under a group health plan upon the occurrence of specific life and work changes -- including marriage, childbirth, death, divorce, job loss, new job, or retirement.
FAMIILIES USA
The Health Assistance Partnership
www.healthassistancepartnership.org/site/PageServer
HAP is a resource for government-supported and nonprofit consumer
health assistance programs (also known as ombudsman). HAP provides
at no cost technical assistance, professional development, and training
opportunities to consumer health assistance programs around the
country. These programs help health care consumers to better understand
and secure their health care rights. HAP works with programs serving
Medicare, Medicaid, and privately insured consumers as well as with
programs working with uninsured clients.
GEORGETOWN UNIVERSITY HEALTH POLICY INSTITUTE
A Consumer Guide For Getting And Keeping Health Insurance
www.healthinsuranceinfo.net/
These Consumer Guides (for each state and the District of Columbia)
are updated periodically as changes in federal and state policy
warrant. The Guides summarize consumer protections.
HEALTH INSURANCE ASSOCIATION OF AMERICA (HIAA®)
HIAA- Guide To Health Insurance
www.hiaa.org/consumer/guidehi.cfm
If you have ever been sick or injured, you know how important
it is to have health coverage. But if you're confused about what
kind is best for you, you're not alone. What types of health coverage
are available? If your employer offers you a choice of health plans,
what should you know before making a decision? In addition to coverage
for medical expenses, do you need some other kind of insurance?
What if you are too ill to work? These are questions that today's
consumers are asking; and these questions aren't necessarily easy
to answer.
HIAA- Guides- Various Types of Insurance
www.hiaa.org/consumer/guides.cfm
What types of health coverage are available? Most Americans know about the kind of health insurance that pays doctor and hospital bills. However, there are many more choices. HIAA has prepared a series of guides on various types of insurance to help you find the answers you need: health insurance, managed care, long-term care, disability, and a special guide for business owners.
HEPATITIS FOUNDATION INTERNATIONAL
Buying Health Insurance
www.hepfi.org/living/liv_buying.html
All health care policies are not created equal. To choose the best plan type for you, you must first understand their differences. Health insurance plans can be broken into two basic categories, the traditional indemnity plan (also called "fee-for service") and the managed-care plan. Premium costs vary depending on the type of plan, location, benefits offered, deductible, and age and sex of the insured. Generally, the indemnity plan is the most expensive followed in decreasing order by PPO plans, POS plans, and HMO plans.
ILLINOIS-DIVISION OF SPECIALIZED CARE FOR CHILDREN internet.dscc.uic.edu/dsccroot/sitemap.asp#what
State Title V CSHSCN Program web site has wonderful info for consumers. Check out:
Health Insurance Resources:
- Choosing and Getting the Most from your Managed Care Plan
- Insurance Terminology for Families
- Understanding Health Insurance
NATIONAL CENTER FOR EDUCATION IN MATERNAL & CHILD HEALTH
Knowledge Path: Child and Adolescent Health Insurance and Access to Care www.mchlibrary.info/KnowledgePaths/kp_insurance.html
This knowledge path about child and adolescent health insurance and access to care offers a selection of recent, high-quality resources and information tools, many with an emphasis on low-income families and SCHIP. It is aimed at health professionals, program administrators, policymakers, and researchers who are interested in tracking timely information on this issue, and it will be updated periodically.
PALO ALTO MEDICAL FOUNDATION
A Simple Guide to Health Insurance
www.pamf.org/physicians/simpleguide/
Millions of people, smart people, are at a total loss when it comes to understanding the jargon of the health insurance industry. Without that understanding, choosing a good health plan is a shot in the dark. Inside this web-booklet are simple definitions, things you should know and questions you should ask to help you evaluate which health plan is best for you and your family. You're not the only one who doesn't know the difference between an HMO, PPO and Point of Service plan.
• Evaluating a Plan
NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA)
Health Plan Report Card
hprc.ncqa.org/frameset.asp
NCQA's Health Plan Report Card can help you answer questions about health plans that would be difficult or impossible to answer on your own-Does this health plan provide good customer service? Will I have access to care I need? Does the plan check doctors' qualifications? If I get sick, which plan will take better care of me?
NCQA's Health Plan Report Card has results on hundreds of health plans that care for commercially insured individuals and Medicare and Medicaid beneficiaries. You can create a customized Report Card that shows results for the health plan or plans you want to know about.
eHEALTH INSURANCE
What Is The Best Health Plan For Me?Questions to Ask
www.ehealthinsurance.org/org/UIInsuranceTips.html
Choosing a health plan can be a confusing experience. Although there is no one "best" plan, there are some plans that will be better than others for you and your family's health needs. We will try to guide you in simple terms. However, rather than just giving you answers, the best thing we can do is to make sure you are equipped with the right questions. There are three major things to consider, each with their own unique set of questions. By considering the questions thoroughly, you will arrive at the right plan for you and your family.
CHILDREN WITH SPECIAL HEALTH CARE NEEDS CONTINUING EDUCATION INSTITUTE
CHILDREN’S HOSPITAL, COLUMBUS , OHIO AND THE DEPARTMENT OF PEDIATRICS
THE OHIO STATE UNIVERSITY
Evaluating Managed Care Plans For CSHCN:A Purchaser's Tool Potential
Applications
www.ichp.edu/managed/materials/
Evaluating Managed Care Plans for CSHCN: A Purchaser's Tool is an
efficient and effective mechanism for describing the capacity of
health plans to serve children, with or without chronic conditions.
Employers, governmental agencies and families are seeking to purchase
comprehensive, high quality, family-centered and affordable health
care for children, including those with chronic conditions. Today,
employers insure close to two-thirds of all children and Medicaid
almost one-fourth. Families also contribute to the purchase of private
health insurance. Decisions about plan choice are made on the basis
of a combination of factors costs, scope of benefits, experience
with plan providers and quality performance. Each of these factors
is addressed below to help purchasers make informed choices
• Health Insurance Terms - Glossaries
See one of the following web sites for definitions of insurance
terminology. It's important to learn and understand the lingo. It
will make it easier when you can speak their language when asking
about the status of claim payment and related benefit questions.
Glossaries of Insurance Terms
HEALTH INSURANCE RESOURCE CENTER
FOR FAMILIES, INDIVIDUALS & SELF-INSURED
A Consumer's Glossary of Health Insurance Terms
www.healthinsurance.org/insterms.html
When shopping for an individual or self-employed health care plan, it is important to understand the terms and phrases used by those proposing health care coverage to you - insurance agents, insurance companies and your provider.
INSTITUTE FOR CHILD HEALTH POLICY, UNIVERSITY OF FLORIDA
NATIONAL CENTER ON FINANCING FOR CSHCN
Glossary for Consumers
 cshcnfinance.ichp.edu/pdf/Glossary%20Finance%20and%20Reimb.pdf
Glossary is intended to provide a brief introduction to terminology used by managed care organizations, federal and state program administrators, health care providers, and health care insurers.
OSF-HEALTH CARE
Health Insurance Terms Glossary
www.stayinginshape.com/3osfcorp/libv/g01.shtml
In dealing with health and insurance matters, you may come across a number of unfamiliar terms. This glossary, adapted from U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services, can help you decipher some of them. Terms may vary from one location to another and from one provider to another, of course, so for specific questions about what a particular term means in your individual case, ask your doctor or insurance provider.
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