Health insurance
can be an expensive addition to a person's monthly budget, and since 2014 it
has been mandatory in the U.S. to have at least a basic level of insurance
coverage.
Knowing the most thorough and
cost-effective coverage option for your family can be difficult but important.
Avoid getting caught short in times of medical need.
Costs
Get to know your coverage before agreeing to a
policy.
There are several ways in which an insurer collects money:
·
Premium: For any
insurer, either you or your employer will pay a monthly premium.
·
Deductible
or excess: This
refers to an amount up to which the insurer will not pay. For example, on a
policy with a $2,000 deductible, you will fund the first $2,000 of treatment
costs. The benefits of your policy become active after the first $2,000 of
costs. A deductible can apply to an individual or a whole family.
·
Co-payment: The
insured pays a fixed amount for each instance of a covers type of treatment. A
visit to a primary care physician, for example, may have a co-payment of $20. A
policyholder would have to pay the co-payment at the clinic. Alternatively, the
clinic deducts the co-payment from the completion of any claim made for the
visit.
·
Co-insurance: This is
similar to a co-payment but works as a percentage of costs rather than a fixed
amount. As an example, a person may have a 20 percent co-insurance on physical therapy appointments. The insurance company
would, therefore, pay 80 percent of treatment costs.
·
Out-of-pocket
maximum: On
some policies, once the insured has paid out a certain amount in expenses
within a single membership year, a certain deductible or co-insurance may no
longer apply.
Deductibles, co-insurances, and co-payments can be used to make sure that
people on an insurance policy only receive treatment within the approved
network. For example, the insured may be charged a 20 percent co-insurance for
treatment at an in-network facility but 50 percent for treatment at a facility
outside of the network.
Depending on your situation, you can also moderate the cost of the monthly
premium by choosing a higher deductible. If you have a low income at present,
this may be the best way to save money on regular insurance costs. However, it
does mean that, in cases of emergency treatment, you will have more to pay on
the day.
Extra costs can emerge when you meet or exceed the annual limit for a
benefit. Some treatments may be covered in full, or without any limit on how
much of one type of treatment a person receives in a year.
However, a person may also have a lifetime limit, meaning that after the
policyholder reaches this amount, they can no longer receive funding from this
policy. Look for a lifetime limit of at least $2 million.
According to an eHealthInsurance
survey from 2013, the
average monthly premiums among its customers were $279 per month for an individual,
with an average deductible of $2,257. Family plans cost an average $605 per
month with a $3,422 deductible.
Health insurance premium
costs rose by
113 percent in the
U.S. from 2001 to 2011. Between 2010 and 2011, a Kaiser Survey showed that the
number of people with health insurance dropped by about 20 million.
To cope with rapidly rising premium costs, millions of people opt for
larger deductibles.
Coverage
It can be hard to define An what is covered by different policies, as
thousands of varied insurance products are available.
Health insurance policies will generally cover:
·
emergency
care
·
inpatient
treatment
·
outpatient
consultations
·
diagnostics,
such as X-ray imaging
Higher-level policies can cover:
·
optical
and dental care
·
maternity
care
·
preventive
treatment and checkups
·
psychological
care
·
prescribed
medicines
·
some
ongoing outpatient therapies
Many insurers offer packages with add-ons. This might help them amend your
policy to suit your changing healthcare needs.
Many policies offer outpatient care up to a certain limit. For example, a
person may have a specific amount of money available to receive up to a certain
number of sessions of physical therapy each year.
Some companies offer special policies to their staff that cover different
parts of healthcare. For example, some airlines include cover for sunglasses on
their pilots' policies, as they are necessary for protecting a pilot's eyesight
during flight.
Underwriting can apply to a policy. This is the process used by an insurer
to establish a basis for accepting risk onto a policy. If a person has already
had a certain condition, it is likely that an insurer will have to pay to treat
this condition further down the line. The insurer has to assess whether this is
a risk they are willing to take.
The process of underwriting may identify a particular condition from your
medical history for which the insurer will not fund treatment. If you declare a
medical condition and it is deemed likely to flare up or occur again within a
certain time frame, it is likely that the insurer will add the condition to
your underwriting and decline to fund treatment for it.
This underwriting can last a lifetime or for a shorter period, depending
on the condition and the policy.
With certain treatments, such as surgeries that reshape the nose, insurers
may request further documents to confirm the medical necessity of the claim and
rule out any undeclared pre-existing conditions. These may include medical
reports, consultant's letters, and imaging scans.
Coverage is normally for domestic treatment only. Treatment in different
countries is usually only available on more expensive policies. People will
normally have to buy either a travel add-on or an entirely separate travel
insurance policy to cover accidents and injuries in other countries.
If your insurance company offers a way to approve or authorize treatment
ahead of time, it may be worth securing this peace of mind. Once approved,
pre-authorization means that an insurance company agrees ahead of time to pay
for treatment.
Insurance companies may sometimes also be able to pay an in-network
hospital directly instead of the patient needing to pay out a large amount of
money and claim for reimbursement.
Most policies will provide a membership guide or document describing
exactly what the agreement covers. Make sure you fully discuss the included
benefits of your policy with your insurer's customer services team or your
broker.
What will an insurer need to confirm cover?
Whether you are making contact before treatment or sending in a claim for
repayment after having finished, your insurer will need various pieces of
information about your treatment.
·
These
may vary from insurer to insurer, but they will standardly include:
·
exactly
what procedures, diagnostic tests, or consultations were carried out
·
an
itemized invoice, so the claims team can exclude ineligible treatments without
affecting those included within the policy
·
the
reason for treatment or the nature of the illness or condition
·
the
name of the doctor and facility
·
the
country or state of treatment
·
the
date of treatment or of each appointment if claims are for a full course of
treatment, such as psychotherapy
·
for
inpatient treatment, a doctor's letter confirming the reason admission is
clinically necessary and the requested length of stay
Failing to provide this information will usually result in a delayed or
incorrectly rejected claim. Be sure to request all necessary information while
you are at the facility.
Exclusions
Insurance companies will refuse to fund treatment that does not align with
the agreed policy.
There are many reasons that this can happen. Specific reasons depend on
the terms of an individual's policy, but common reasons for the rejection of a
claim include:
·
Treatment
was received for an underwritten or previously undisclosed pre-existing
condition.
·
The
doctor was not an appropriate type of physician to treat the named condition.
·
Aesthetic
or cosmetic treatment was received for non-medical reasons.
·
The
benefit or permitted funds for a particular treatment had been used up for the
coverage period by the time treatment was received.
·
Preventive
care was received, such as a full checkup, on a policy that only covers active
treatment, or the treatment of diseases and conditions.
·
A
person has tried to purchase devices or physical aids, such as orthotic
in-soles for foot problems, on a policy that does not cover these.
·
A
individual receives treatment during a break in cover.
·
The
claim was for administrative costs, such as the printing of medical reports.
·
The
insured claimed for contraception or family planning, and these are generally
not covered.
An insurer will not cover treatment if an individual receives it for a
condition that is under a moratorium. Moratorium refers to a particular period
during which an insurer will not fund treatment for a condition. However, after
the closing date of the moratorium period, the insurer can add the condition to
the policy.
For example, some policies may include a moratorium on maternity care in
the first 10 months to prevent people from buying a policy when expecting a
child and immediately making a huge claim and then canceling. During this time,
maternity visits or the inpatient delivery of an infant will not be funded.
However, after 10 months, the insurer will pay for these treatments.
In some cases, a claim will only be partly paid if the provider of
treatment charged more than was reasonable and customary in that area. If an
osteopath in a certain area would normally charge $100 for a consultation, and
a patient submits an invoice for $180, the insurer will often only pay up to
the reasonable and customary fee.
This can often be avoided by staying within the provider network, where
set fees will have been agreed.
Often, an insurer will pay the parts of the claim that are eligible for cover
and exclude parts that would not fit under the policy. This is known as a
shortfall.
Choosing a policy
An insurance broker or intermediary can help
you better understand your coverage needs and buy a policy that matches them.
An insurance broker or intermediary can help you better understand your
coverage needs and buy a policy that matches them.
With all of these options available, it can seem overwhelming to choose a
policy that is right for you and your family.
When coverage is available through an employer, it can be a great way to
access an often-enhanced set of benefits at a reduced cost. However, not all
employers offer health insurance as a perk.
There are some important factors to bear in mind when choosing a policy.
These include:
·
whether
to collect all members the family onto one plan or have each member on a
separate plan
·
your
current doctor being in the network for a particular insurer
·
making
sure the options you choose in the policy are right for your health needs
·
the
size of your deductible and whether you would prefer to pay more as a regular
premium or more when treatment is necessary
·
the
amount of time spent outside the country – if you travel for many months of the
year, you may benefit from a policy that covers more than just your country of
residence
You may wish to get an insurance policy through a broker or intermediary.
While their services may cost a little extra on top of your premium, they can
provide a clearer breakdown of the available options and how they will impact
you and your family and make sure you get the fairest deal.
Get to know your coverage before agreeing to a
policy.
An insurance broker or intermediary can help
you better understand your coverage needs and buy a policy that matches them.