Health & Wellness > Navigating Healthcare

Navigating the Healthcare System

Basic Health Insurance

Basic health insurance is frequently sold as a separate policy from major medical insurance. It can also be sold as part of a combination policy that includes basic and major medical in one comprehensive plan. It includes basic hospitalization and basic medical coverage. It's often packaged with medical/surgical insurance. There are time and dollar limits. Basic health pays your expenses for hospital room and board, use of the surgical suite, lab tests and X-rays. Medical/Surgical pays for operations in a hospital or as an outpatient. This would pay the surgeon, the assistants and the anesthesiologist. It would usually cover physician fees for all hospital stays, not just for surgeries, and sometimes pays outpatient medical costs such as tests and physical therapy. Be sure to check with your insurance agent or broker to see exactly what your Basic Health Insurance Covers.

Dreaded Disease Policies

A supplemental dreaded disease policy is designed to protect against a terminal or financially taxing disease. Before buying one, check to be sure the benefits aren't matched by your regular health insurance. The most useful policies don't put limits on conditions or name specific diseases to be covered. Even though you have medical insurance, supplemental health insurance could cover co-payments and non-medical expenses such as lost wages, travel costs and other household expenses. Study the benefits carefully and make sure they will meet your needs. But don't pay extra for duplicate coverage you don't need.

Group Health Insurance

Group health insurance is one of the best benefits available. However, it's not offered by every company, and sometimes the coverage isn't comprehensive enough. It's important to know exactly what your group health insurance covers before you need it. That way, you'll know what expenses you'll be responsible for and can decide what additional coverage you'll need. The first thing to check is if there are any limits on pre-existing conditions. Some policies will not pay for a condition you had prior to coverage. Most good basic policies are renewable when you retire or leave the job, provide coverage for your entire family from the day of their birth until they leave home and cover all congenital problems and illnesses. You might also like a policy that has no maximum charges per illness and that covers all hospital fees and offers full coverage of home health care expenses.

Health Maintenance Organizations

Health Maintenance Organizations are an alternative to traditional insurance for many people and businesses. Basically an HMO is a pool of physicians who offer health care to patients for a flat monthly fee instead of accepting health insurance payments. The fee doesn't change, regardless of how much medical attention you may need. You can only visit a doctor or hospital that is affiliated with the HMO. With health insurance, you pay the deductible amount each time you are treated, but with an HMO, you pay only a fixed monthly fee. Depending on the number of doctor visits, you could save money with an HMO. Other typical HMO offerings include routine medical checkups, continuous care, emergency procedures and prescription coverage. For more information, talk with your agent.

Hospital Indemnity Policies

You've seen the ads promising a certain number of dollars per day while you're in the hospital. These are known as “hospital indemnity,? or “hospital income,? policies. They are usually pretty inexpensive and pay a set number of dollars per day when you're hospitalized. Before you decide to buy one, you need to evaluate your regular health insurance and any Medigap policy you may own. Don't count on a hospital indemnity policy for basic coverage. The daily dollar amount usually doesn't rise with inflation. So what seems like a good deal now, may not be in a few years. Also, these policies may have a waiting period of 7 to 10 days, so you may not be paid for short hospital stays.

Individual Coverage

Since individual health insurance is expensive, you need a strategy for buying a policy. Experts agree that you should insure yourself and your family against the worst imaginable circumstances. Buy the highest deductible you can afford. Self-insure yourself for the small bills. It's the large, enormous medical bills that you want to insure against. If your insurance funds are limited, buy major medical coverage first. Since major medical covers major, extended incidents, you'll get the most for your insurance dollar. Also, it's better to buy health insurance while you're still healthy because after a major illness, you may be denied coverage, and if you are accepted, your premiums will probably be much higher.

Long Term Care

Looking into long-term care insurance? Here are some buying tips: Look for a policy that is guaranteed renewable, and does not require prior hospitalization before admission to a nursing home. Find out if premiums are waived if you are in a nursing home and make the effort to understand the level of benefits, how many years they will last and how soon after admission they will start. The best policies pay a generous daily benefit for care resulting from illness, injury, physical and cognitive impairments. They cover custodial care and intermediate care as well as skilled nursing care. If you decide you want a policy, you'll find the premiums are far less expensive if you sign up in your fifties or early sixties. Long-term care insurance makes financial sense for people who have substantial assets. Those who do not may qualify for Medicaid...the government low-income health care program that pays for long-term nursing home care. Long-term care insurance is growing in popularity and importance.

Major Medical Insurance

If you don't have any health insurance, Major Medical should probably be your highest priority. Major picks up where Basic Health leaves off, and is often sold in combination with Basic Health. Major Medical covers extended major injuries and illnesses--the kind of catastrophic health problem that can wipe you out financially. Major medical usually includes hospitalization, doctor fees, diagnostic work, surgery, home care, rehabilitation, blood and drugs. There's no time limit because major medical is designed to cover prolonged treatment. You usually are responsible for co-payments, deductibles and 20 percent of the charges. When you buy a combined basic health/major medical policy, it's called “Comprehensive? health insurance.?

Managed Care

Because health care costs keep rising, various forms of managed care are quickly displacing traditional insurance. In managed care, you are a member of an HMO or another type of healthcare network that combines physicians, hospitals and support services. In the most common form, the HMO, you select a primary care physician who must approve all medical treatment, including referrals to specialists. The HMO pays the physician on a per-patient basis. If the physician can keep the cost of medical care low, he or she is rewarded financially. Participants in the network, who also include specialists, therapists, hospitals, labs and clinics, also agree to cost-containment measures such as discounts, price caps and utilization reviews. From a consumer's point of view, managed care usually offers lower premiums, low or no deductibles and a larger number of covered services. There are usually co-payments for office visits and other services. In a managed care system, there is less reliance on specialists, and a greater emphasis on preventive care.


All Americans qualify for Medicare on their 65th birthday. Certain people with long-term disabilities and kidney problems also qualify. Medicare has two parts, Part 1, which is essentially hospital insurance, and Part B, which covers physicians' and surgeons' charges both in and out of the hospital. Part B is optional, so you pay a monthly premium. Because of the large volume of Medicare recipients, the program also determines what are "allowable" charges and hospital expenses. Medicare was never designed as an all-inclusive health program; it was to relieve older Americans of some of their health care costs. That means you probably need additional coverage. To apply for Medicare, contact the Social Security office nearest you a few months before you turn 65. To learn about Medigap supplemental policies, talk to your agent.

Medicare Supplemental Policies

Medicare supplemental policies are designed to cover the co-payments not covered by Medicare and to pay Medicare-eligible expenses after Medicare's limits have been reached. Depending on the policy, it may cover the Part A or Part B deductibles or both, and some may cover services that Medicare doesn't cover, like out-of-hospital prescription drugs. Still, there may be some expenses that even a supplemental policy won't cover, like foot care, glasses, hearing aids or cosmetic surgery. Always check your policy carefully. It is just as important to know what is not covered as to know what is covered. Also, each state has adopted minimum standards for supplemental policies. Check with your state insurance department if you have questions about their laws or policies, companies or agents.

Medicare supplemental policies are designed to cover the co-payments not covered by Medicare and to pay Medicare-eligible expenses after Medicare's limits have been reached.

PPOs /POS Plans

What is a PPO? It's a Preferred Provider Organization, a form of managed care that allows consumers to retain more choice over physicians and hospitals than the better-known HMO's.Preferred Provider Organizations are networks of primary care physicians, clinics, labs, therapists and hospitals. The insured person is not required to use this network, but is rewarded with far more generous reimbursements if they do. A POS is similar. It's a “point of service? plan. Like a PPO, a POS has a health care network. Like an HMO, participants have a primary care physician who must approve all medical care. However consumers retain the right to go outside the network. If they do, their costs will be higher and the coverage won't be as comprehensive.

Pre-existing Conditions

Most health policies have a pre-existing condition clause. If you're in good health when you apply, there's little to worry about. But if like many people, you have current or recent serious health problems, the preexisting conditions clause might prevent you from obtaining care you need. Before you buy any policy talk to the agent or broker about the company's definition of a pre-existing condition. And read the clause's a written part of the policy. Some pre-existing condition clauses exclude the health condition permanently. It's more common to have time limits, which can be as long as five years. Some group policies waive the pre-existing condition clause o r have shorter waiting periods.

Health insurance benefits

Medical care can be extremely expensive, but good health insurance can save you lots of money in the long run. Many companies offer their employees group health insurance coverage. Health insurance can prevent financial disaster in case you need major surgery or long term medical care. Basic health insurance generally reimburses you for doctor's bills, medication, outpatient surgical procedures, and other medical expenses up to a preset dollar amount. You may decide to purchase major medical insurance to cover hospital visits and major medical procedures. Many health insurance policies require that you pay a deductible of one hundred to one thousand dollars before the insurance reimburses any medical bills. It's a good idea to buy a policy that can be renewed no matter how many times you make claims against it. Consult a health insurance professional in your area for more information about health insurance benefits.

Benefits of having COBRA insurance

The congressional omnibus (AHM- nuh -bus) budget reconciliation act or Cobra (KOH- bruh ) gives you the right to carry your group health insurance coverage to your new job for up to eighteen months. You lose the right to this benefit if you're fired for cause or misconduct. Even though you're required to pay the full premium with Cobra, you'll still have the group rate, which can be a lot less expensive than individual rates. If you become unemployed, or leave a company to become self-employed, you may still keep your Cobra health insurance for up to eighteen months. Others who are eligible for Cobra benefits are widows, widowers, children of employees who die while still employed by the company, spouses who divorce employees, and employees' children. Consult an insurance agent in your area for more information about Cobra benefits.

Dental insurance data

Not every company offers dental insurance, and caring for your teeth is not something to put off. Adequate dental insurance is available to help you cover the costs of your dental needs. Consider what services you'd like covered. You may want your coverage to include orthodontics, especially if you have children who may need braces. Coverage for oral surgery can help if older children need their wisdom teeth removed. Consider coverage for restorative dentistry or prosthodontics (pros- tho -DON-ticks) for care for your aging teeth. And of course, see what coverage is available for preventive dentistry and routine office visits. Sometimes teeth cleaning and fluoride treatments are free under dental insurance. Consult a health insurance agent in your area for more information about dental insurance.

Defining disability

If you become unable to work due to an injury, the loss of income could be devastating. Injuries and illnesses can require extensive medical care resulting in enormous expenses. Disability income insurance can prevent financial disaster, should you become unable to work. Good disability policies include benefits equivalent to sixty to seventy percent of your current gross income. Some policies offer lower premiums, but don't pay immediately upon disability. Your disability insurance should cover both accident and illness, and it's a good idea to ask your insurance agent about non-cancelable renewals. Consult an insurance agency in your area for more information about disability insurance.

Insurance provided by your employer

Many employers offer medical insurance plans that are adequate for family needs. Not only can this eliminate the need for individual health insurance, but it's also generally the least expensive and easiest form of insurance protection. If both spouses work, it's a good idea to review both plans thoroughly before selecting which insurance to use. Your premiums can often be deducted right from your paycheck, and your policy generally can't be cancelled regardless of how many claims you file. Different employers offer various plans, and some basic plans provide more coverage than others. Consult a health insurance professional in your area for more information regarding employer provided insurance.

About governmental health programs

Medicaid and Medicare are the two basic types of governmental health programs. Medicare, which is a federal insurance program, generally covers Americans who are sixty-five or over, and those with specific disabilities, including permanent kidney failure. The two main parts of Medicare are hospitalization and supplemental medical care. Medicaid is a federally funded program that's administered by the state. This program is designed to provide health insurance for those who can't afford it. Your local welfare office can help you determine if you're eligible for Medicaid. Your local social security office can give you information about applying for Medicare. Consult an insurance agent in your area for more information.

How do I check my coverage?

It's a good idea to evaluate your health insurance coverage to ensure that your policy provides adequate coverage for your needs. Start by asking your insurance agent these basic questions to check your coverage. Does the insurance only cover a specified amount per day, or does it cover usual customary costs? Does it exclude coverage for specific illnesses or accidents? Does the plan cover pregnancy for married and unmarried employees, and will it cover the newborn from birth? How long are the insured person's children covered? What about outpatient and emergency treatment? What time limits apply to submitting claims? Consult a health insurance professional in your area for help evaluating your health insurance coverage.

Coverage through social security

Social Security health coverage is divided into several parts in the Medicare Health Insurance Program. The first part, called Part A, is for hospital insurance and is paid for through Social Security taxes. Those eligible for Social Security receive Part A Medicare health coverage at no additional cost. The second part of the coverage, known as Part B, is voluntary supplemental insurance. If Social Security recipients decide they need Part B coverage, payment can be deducted monthly from their Social Security checks. Social Security recipients are automatically covered by Part A until they withdraw from the program, but it's a good idea to call your local Social Security office two to three months before you turn sixty-five to find out about all the coverage available. Call your local Social Security office for more information about health insurance through Social Security.

Health insurance options

There are three basic types of health insurance protection. The first type is called a fee-for-service indemnity plan. This insurance provides coverage for hospital, surgical and medical needs, such as major medical, comprehensive, catastrophic, and dental plans. The policies can be purchased through commercial insurance companies, or independent organizations as well as Blue Cross-Blue Shield. Your rates and levels of coverage may vary depending on the type and amount of coverage you desire. The second type of health insurance consists of prepaid health care plans such as Health Maintenance Organizations, or H-M-O's and Preferred Provider Organizations, or P-P-O's. These organizations are networks of doctors, hospitals, and other health care professionals that provide members with prepaid medical care. Rather than a premium, members are charged a flat monthly or quarterly fee. The third type is governmental health insurance, such as Medicare or Medicaid. You can check with your local government offices to see if you qualify for governmental health coverage. Consult a health insurance professional in your area for more information about your health insurance options.

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