There are many types of health insurance plans:
- Managed Health Care Plans: Health Maintenance Organizations (HMOs), Point of Service (POS) Plans, Preferred Provider Plans (PPOs)
- Pay-as-you-go plans
- Coverage for catastrophic diseases
- Medical expense savings accounts
- Medical compensation policies
- Cancer insurance and other supplemental insurance
All of these plans require you to pay a monthly fee, referred to as the premium. Most also require you to pay either a fixed fee for doctor’s appointments and other services (known as co-pay), or a percentage of the cost (referred to as coinsurance). Some services require you to pay for a co-payment and coinsurance. Each year, most people also pay a certain amount of their health care costs (known as the deductible) before their insurance begins to cover their medical expenses. Once you’ve covered the deductible, your insurance will pay a set percentage of your health care bills for the rest of the year.
- Deductible: The amount you must pay each year for health services before the health plan pays for something.
- Copayments: The amount you must pay at the time of service, commonly a fixed fee each time you visit your doctor or receive other services. Sometimes they get confused with coinsurance, but they’re not the same.
- Coinsurance: A percentage of each medical bill you must pay, even after you have paid the annual deductible amount.
If your doctor accepts your health plan, the office will often send the bill to the insurer, and then send an invoice to you for the amount your health insurance does not cover. If not, you may have to pay your medical bills and then complete the formats and send them to the insurance company to reimburse your health care expenses.
You have to keep track of your own medical expenses and payments made by you and your insurance company. These records can help you in case there is a dispute about your payments or any other problems in the future. For more information, see Save copies of important medical reports.
Health plans are briefly explained below. Although we will describe the types of health plans you may find in the private sector (employer-provided plans and individual insurance plans), many of the government-sponsored plans use some of the same approaches and terms as private plans. You can learn more about government-funded health plans, such as Medicare, Medicaid, and CHIP.
It’s important to know that some health plans may not cover all of your health care needs. Here are some things to consider when selecting a plan:
- Verify that the plan is classified as a Qualified Health Plan.
- Confirm that your doctors, specialists, and pharmacies are part of the new provider network. If not, check out-of-network provider service costs.
- Confirm that your current drugs are covered on the plan’s drug form.
- Review all health care services covered by the plan, as well as excluded and limited coverage services.
Each health plan is different, but some of the commonly excluded and limited coverage services include: unproven and experimental therapies for cancer, acupuncture, homeopathic or herbal medications, long-term care, private nursing, non-prescription medications or services, equipment, and products that may not be medically necessary for your health care.
Health insurance scams are everywhere
Be well alert for health insurance scams (ads or agents that offer discount medical cards, or “government-sponsored” and therefore very low-cost health insurance). There are also “insurance specialists” or “government agents” who call and ask for personal data or credit and banking information. These scammers operate online, by phone and door-to-door.
Managed health care plans
These types of plans typically coordinate or manage the health care of enrollees. There are several types of managed health care plans. some plans, such as health care organizations (HMO), have a more limited network of providers and hospitals, while other models, such as preferred provider organizations (PPO) have a broader provider network.
Not only do health insurance companies, but many diverse types of institutions and agencies also sponsor managed health care plans. These include employers, hospitals, trade unions, consumer groups and the government, among others. It’s helpful to know the details of the plan and how they affect your health care. The most common types of managed health care plans are:
- Health Maintenance Organizations (HMO)
- Point-of-service plans
- Preferred Provider Plans
Most managed health care plans have lower premiums, copayments, and/or coinsurance than traditional pay-as-you-go insurance. Premium, co-pay, and coinsurance amounts may vary between managed health care companies, and even between the various services within the same company. It is generally not required to process claim formats.
Some managed health care plans require your enrollees to use a primary health care provider that coordinates all of a patient’s care and has the function of channeling care to other specialists. This doctor who channels is usually a primary care doctor responsible for the general medical care of the patient, and is responsible for organizing and approving medical treatments, tests, referrals to specialists and hospitalizations. For example, if you require consultation with a doctor who specializes in your lungs, you should be referred by your primary care doctor before the specialist can care for you. Otherwise, your plan may not pay for the service.
In most plans, affiliates will need to use only the services of certain providers and health care institutions with whom they have agreements. These plans may require affiliates to opt for providers from a particular list or network of providers. When you choose to get care from an out-of-network provider, you usually pay more, or even pay the full bill without your health plan’s help. Some of these plans will require you to pay at least part of the cost for consulting someone outside the network in case you get approval of the plan before incurring the consultation or service (also referred to as pre-authorization).
Health Maintenance Organizations (HMOs)
The HMO plan will generally cover most expenses after your co-pay and you pay your deductible. HMO plans often limit your selection of health care providers to those approved in the provider network. This means that you should review the list to make sure that the doctor you want to consult is one of the doctors within this network. Otherwise, the invoice may not be covered in whole or in part.
Point of Service Plans (POS)
A POS plan is a type of HMO. Primary care physicians in a POS plan usually refer cases to other doctors in the health care plan or network. If your doctor refers you to a doctor who is not part of the plan (out of the network), before you go to the plan, you will need to check whether the plan will partially or completely cover the bill. But if you choose an out-of-network doctor, you’ll have to pay for coinsurance, even if the service is covered by the plan.
Preferred Provider Organizations (PPO)
A PPO plan is a hybrid of a traditional pay-per-service plan (described below) and an HMO plan. Like an HMO plan, you have a number of doctors and hospitals you can go to to get the lowest cost-sharing. When using the services of such physicians (sometimes referred to as preferred providers or network providers), most of your bills are covered. You’ll have to pay more money when you select health care providers that aren’t part of the network.
Go for out-of-network medical care
Sometimes you will need to go to an out-of-network care center for medical care. It may cost more, but you can reduce your costs by talking about this issue with your health plan administrator, as sometimes they pay more if you understand that this is necessary. Contact your insurer to find out what you will pay and how much you will have to pay, or if you require prior authorization to get care outside the provider network.
You can also negotiate costs in advance with your doctors, clinics, and hospitals when planning surgeries, procedures, or other treatments. You can use the information you get from your health plan to find out if the health care center (hospital, clinic, doctor’s office, etc.). you are willing to accept the amount paid for the insurance as a full payment. If not, ask if you are willing to discount the part you have been asked to pay.
You can also appeal your plan’s decision if you disagree to cover out-of-network care. See What to do if your health plan denies your claim.
Pay-as-you-go plans are the least restricted and offer the widest range of health care providers. They are also known as traditional health plans. If you have this type of health insurance, you can consult any doctor or hospital that accepts your particular health plan and change doctors at any time.
Other types of health coverage
Some other types of insurance suggest that they pay for hospitalization and higher medical expenses, but these claims can be misleading as not all information is disclosed. You’ll need to find out more to make an information-based decision.
Coverage for catastrophic diseases
Treating and managing most cancer cases costs a lot of money. Some health plans offer supplemental coverage called catastrophic coverage. These plans do NOT cover routine medical expenses, but may only help cover the most serious health cases, such as a serious illness or injury. These often seem attractive because they have fairly low premiums. It’s important to know that these plans generally have high deductibles and routine medical expenses are the patient’s responsibility (unless you also have other coverage along with catastrophic coverage).
An example is insurance that covers catastrophic disease known as a hospital-only plan. This plan generally doesn’t offer coverage for doctor’s appointments, medications, or routine medical care, and only begins to cover when very high hospitalization and expenses arise. Depending on the policy, you are expected to pay a few thousand dollars (USD) only for the deductible and a certain percentage of coinsurance on the rest of the bill. You will also have to pay for the full cost of any item and service that does not cover the plan.
Although they are sometimes called hospital-only, plans won’t necessarily cover all or even most of your hospital bill. It’s important to understand exactly what the plan will cover and not rely on the plan for catastrophic diseases such as health coverage.
Coverage plans for catastrophic diseases may be offered in some low-income or exempt state health insurance markets. People with this exemption because of difficult living conditions do not have to pay a penalty when paying the tax return. However, a person applying to be exempted from purchasing a regular health plan cannot be assisted in paying premiums for coverage for catastrophic diseases, even if income is very low. Still, coverage plans for catastrophic diseases in health insurance markets have advantages over those not acquired in these markets. Catastrophic plans sold in the health insurance marketplace have to cover three annual doctor visits and preventive benefits.
If you have a coverage plan for catastrophic diseases and have a disease that carries many expenses such as cancer, you can pay out-of-pocket a high deductible and up to 40% of your hospital bills. Most catastrophic plans have a disbursement limit, but services that the plan does not cover do not count for that limit. For example, catastrophic plans typically don’t cover prescription drugs, which can be expensive to consider that some of the latest cancer treatment drugs cost more than $100,000 (USD) per year.
In addition, catastrophic plans may end up costing more than the disbursement limit if the person receives out-of-network care. If you opt for that plan, see if prescription drugs are covered, ask about out-of-network services costs, and see if any of these expenses will be included in the disbursement limit.
Health expense savings account, reimbursement plans for medical expenses, and more
If you have joined or plan to join an insurance plan that has a high deductible, such as a plan for catastrophic diseases, you may want to open a Health Savings Account (HSA). You do not have to pay federal taxes for contributions you make to the account if the money is used to pay for eligible medical expenses. If you use the money to cover any other expenses, you will be required to pay the applicable tax as well as a penalty.
A Medical Expense Savings Account (HSA) is different from a Flexible Spending Account (FSA). For example, you may have an FSA even if you don’t have a high-deductible health plan. FSA funds can be established to pay for medical expenses or for expenses for a dependent’s care. You will need to use the full amount by the end of the year (“or use it, or lose it”). In an HSA account, however, the money is still yours. For more information on how to open an HSA account, you can contact your employer, bank, or credit union.
There is also an employer-funded Health Reimbursement Arrangement (HRA) plan that consists of a special benefit that pays for medical expenses not covered by the health plan, such as deductibles and coinsurance. However, it is the employer that provides the money and decides which expenses to pay. The employer also decides whether any leftover money in an HRA can be transferred to the next year. In addition, you lose the money if you leave the company.
Hospital compensation policies, cancer insurance and other supplemental or health-related insurance
Hospital compensation policies, sometimes referred to as supplemental health care policies, pay a fixed amount for each day you are admitted to a hospital. There may be a limit to the total number of hospitalization days that will be paid in a calendar year, or a cap on the number of days that will be covered. The money you receive for this type of policy can be used according to the insured person’s wishes. It is typically used for health care costs that are not covered by the health plan, or for other expenses that families face when one of the family members becomes ill.
These supplemental plans do not offer the type of coverage needed for a disease such as cancer. Therefore, if this is your only form of bucket, you will also pay a considerable amount of cash if you are diagnosed with a serious illness.
Critical illness and cancer insurance policies
There are other types of policies that offer additional money for certain types of health problems, such as cancer, stroke, or if you have an accident. They usually cover a portion of the expenses that your regular health insurance does not cover, such as deductible and coinsurance. Others only offer a fixed amount of money from the diagnosis. These policies cannot be purchased after the event or diagnosis, and generally involve limitations and waiting periods. It is important to understand exactly what the plan will cover and not rely on this type of policy for catastrophic diseases such as health coverage. These policies DO NOT cover most of the health care services a patient needs.
Long-term care insurance
This type of insurance is NOT of medical care itself, but it helps cover long-term care, whether medical or non-medical, for people who require help to carry out their daily activities such as eating, dressing, walking, going to the bathroom or bathing. Unpaid family members often provide this type of home care, but that option is not available to everyone. Long-term services could be offered at home by paid staff, or in community households, in assisted residences or in nursing homes.
The terms of long-term insurance policies vary. For example, most policies do not start making payment for the service until more than 90 days have elapsed after the need arises, but some take effect even after one year. Home health care may be covered separately or may not be covered at all by certain policies. Long-term care insurance can be too expensive. Medicare and most health care insurance plans do not cover the cost of long-term care. Some states cover long-term care through Medicaid for people who qualify for this program and who meet other requirements of the state in which they live.
You can learn more about the types of health insurance plans at producenci.top.
You can also refer to the Additional Resources tab at the bottom of the page for organizations that can give you more information about your health insurance options.