Health Insurance Terms
actuary - a mathematician in the insurance field. Responsible for calculating premiums, developing plans and defining underwriting risk. agent - a licensed individual who represents several insurance companies and sells their products. benefit - reimbursement for covered medical expenses as specified by the plan. brand-name drug - prescription drug which is marketed with a specific brand name by the company that manufactures it. May cost insured individuals a higher co-pay than generic drugs on...
Read MoreA Final Word
If you get health care coverage at work, or through a trade or professional association or a union, you are almost certainly enrolled under a group contract. Generally, the contract is between the group and the insurer, and your employer has done comparison shopping before offering the plan to the employees. Nevertheless, while some employers only offer one plan, some offer more than one. Compare plans carefully! If you are buying individual insurance, or any form of insurance that you purchase...
Read MoreOther Forms of Health Insurance
In addition to broad coverage for medical, surgical, and hospital expenses, there are many other kinds of health insurance. Hospital-surgical policies, sometimes called basic health insurance, provide benefits when you have a covered condition that requires hospitalization. These benefits typically include room and board and other hospital services, surgery, physicians’ non surgical services that are performed in a hospital, expenses for diagnostic X-rays and laboratory tests, and room...
Read MoreComparing Plans
Whether you end up choosing a fee-for-service plan or a form of managed care, you must examine a benefits summary or an outline of coverage – the description of policy benefits, exclusions, and provisions that makes it easier to understand a particular policy and compare it with others. Look at this information closely. Think about your personal situation. After all, you may not mind that pregnancy is not covered, but you may want coverage for psychological counseling. Do you want...
Read MoreFrequently Asked Questions
Q What is the first thing I should know about buying health coverage? A Your aim should be to insure yourself and your family against the most serious and financially disastrous losses that can result from an illness or accident. If you are offered health benefits at work, carefully review the plans’ literature to make sure the one you select fits your needs. If you purchase individual coverage, buy a policy that will cover major expenses and pay them to the highest maximum level. Save...
Read MoreWhat Happens to My Insurance if I Lose My Job?
If you have had health coverage as an employee benefit and you leave your job, voluntarily or otherwise, one of your first concerns will be maintaining protection against the costs of health care. You can do this in one of several ways: First, you should know that under a federal law (the Consolidated Omnibus Budget Reconciliation Act of 1985, commonly known as COBRA), group health plans sponsored by employers with 20 or more employees are required to offer continued coverage for you and your...
Read MoreWhat Is Not Covered?
While HMO benefits are generally more comprehensive than those of traditional fee-for-service plans, no health plan will cover every medical expense. Very few plans cover eyeglasses and hearing aids because these are considered budgetable expenses. Very few cover elective cosmetic surgery, except to correct damage caused by a covered accidental injury. Some fee-for-service plans do not cover checkups. Procedures that are considered experimental may not be covered either. And some plans cover...
Read MorePre-existing Conditions
Many people worry about coverage for preexisting conditions, especially when they change jobs. The Health Insurance Portability and Accountability Act (HIPAA) helps assure continued health insurance coverage for employees and their dependents. Starting July 1, 1997, insurers could impose only one 12-month waiting period for any preexisting condition treated or diagnosed in the previous six months. Your prior health insurance coverage will be credited toward the preexisting condition exclusion...
Read MoreHow Do I Get Health Coverage?
Health insurance is generally available through groups and to individuals. Premiums – the regular fees that you pay for health insurance coverage – are generally lower for group coverage. When you receive group insurance at work, the premium usually is paid through your employer. Group insurance is typically offered through employers, although unions, professional associations, and other organizations also offer it. As an employee benefit, group health insurance has many advantages....
Read MoreAppropriate Care
HMOs, PPOs, and fee-for-service plans often share certain features, including pre authorization, utilization review, and discharge planning. For example, you may be asked to get authorization from your plan or insurer before admission to a hospital for certain types of surgery. Utilization review is the process by which a plan determines whether a specific medical or surgical service is appropriate and/or medically necessary. Discharge planning is an approach that facilitates the transfer of a...
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