Insurance

Choosing a Health Insurance Plan FAQs

Are you trying to decide on a health insurance plan? There are many different types of plans available. Most people get their health insurance through work. Others have to find an insurance company and choose a plan for themselves. The Agency for Healthcare Research and Quality (AHRQ) provides valuable information to help in your decision. Here are some frequently asked questions about choosing a health insurance plan.



Q:

What types of health care plans are available?



  • A:

    The most common types of health plans are fee-for-service and managed care. There are various types of managed care plans, including:

    • HMOs
    • PPOs
    • IPAs
    • POS plans



Q:

What's a fee-for-service plan?



  • A:

    A fee-for-service health plan is the traditional type of health care policy. Your health insurance company will help pay part of your medical costs. You must pay a deductible before the insurance company will pay anything. You're also responsible for paying monthly fees, called premiums. However, you can usually choose whatever doctor or hospital you want.



Q:

What's an HMO?



  • A:

    HMOs, or Health Maintenance Organizations, are health plans that are prepaid on a monthly basis. You and your family will be provided medical care under the plan. HMOs usually offer lower overall costs compared to fee-for-service insurance. However, you're usually limited to the doctors that have an agreement with your HMO.



Q:

What's a PPO?



  • A:

    A PPO, or Preferred Provider Organization, is a combination of a fee-for-service plan and an HMO. If you want most of your medical costs covered, you're limited in what doctors and hospitals you can choose. However, you can choose a doctor outside of the plan if you're willing to pay more of the medical costs.



Q:

What's an IPA?



  • A:

    An IPA, or Independent Practice Association, is a group of private doctors who provide medical care. The IPA contracts with HMOs to provide medical services to the members. If you're the member of an IPA-type HMO, you can pick one of the participating doctors off the IPA network list.



Q:

What's a POS health plan?



  • A:

    A POS, or Point-of-Service, plan gives you flexibility in either choosing services in-network or out-of-network. You usually have to pay more money for out-of-network medical services.




Q:

What's the best health care plan for me?



  • A:

    Every health care plan has strengths and weaknesses. There's no plan that's best for every situation. What's best for you will depend on your specific situation.



Q:

Do I have to file claim forms if I choose an HMO?



  • A:

    Most HMOs don't require members to file claim forms. You're given a medical card that you give to the doctor or hospital when you need medical care.



Q:

Do I have to file claim forms if I choose a traditional fee-for-service plan?



  • A:

    You might have to file forms and send them to your insurer to seek payment for medical expenses.



Q:

Will my health care plan pay whatever the doctor charges?



  • A:

    Your insurance plan will normally pay whatever's reasonable and customary for the medical service. It doesn't matter how much the doctor is trying to charge. Many times the doctors and hospitals will accept the reduced fees as paid in full.



Q:

Can I choose any doctor I want in my health care plan?



  • A:

    You can choose any doctor you want in a traditional fee-for-service plan. However, you normally must pick a doctor in the network in managed care health plans. Some plans, such as PPOs and POS plans, will allow you to choose doctors outside the network, but you might have to pay a larger portion of the medical costs.



Q:

What's a primary care physician?



  • A:

    Your primary care physician, or PCP, is the main doctor responsible for your medical care. Many health care plans require you to go through your primary care physician for any type of medical service. She'll coordinate your health care and recommend any specialists that you need.



Q:

What should I look for generally in a health care plan?



  • A:

    Make sure to find out what each plan will cover in terms of medical costs. You should be aware of any limitations in the coverage. Examine several different types of plans. Compare and contrast the coverage and costs of each plan, and choose the one that best fits your needs.



Q:

What should I look for in a fee-for-service health care plan?



  • A:

    Examine the monthly premium and the deductible. Do they seem reasonable compared to other plans? Looks at the extent of medical coverage. Does it cover all medical costs or just the basics? Try to determine the maximum amount you would have to pay in a year if there was a major medical emergency.



Q:

What should I look for in an HMO?



  • A:

    Since HMOs limit the doctors and hospitals you can use, check to see if you can continue to use your current doctor. Sometimes it can take longer to see a doctor in an HMO plan than a fee-for-service plan. Attempt to find out the ease of making appointments and the length of time it takes to see the doctor. Ask how much the HMO plan will cost you for the year.



Q:

Do all traditional fee-for-service plans provide the same medical coverage?



  • A:

    Your fee-for-service plan may offer basic medical coverage, major medical coverage or both. Basic coverage pays the lower, short-term medical costs, such as hospital rooms and x-rays. Major medical covers the high cost of a serious injury or a long-term illness. Look for a plan that offers both to fully protect yourself.



Q:

What's preventive care and is it covered under the health insurance plans?



  • A:

    Preventive care focuses on maintaining good health and detecting any medical problems early. Many health care plans cover preventative care, such as immunizations, routine physicals and mammograms.



Q:

What's the difference between group and individual insurance?



  • A:

    Most people have group insurance through work. This insurance can usually be offered at a lower rate since it covers a large number of people. Individual insurance is usually for those people who can't get insurance through work and have to enter into a health insurance plan individually.



Q: Can my spouse and I collect on two different insurance plans?

  • A:

    Yes, although you're usually limited to 100 percent of your medical claim in total.



Q:

What's a "free look clause" and how does it protect me?



  • A:

    Many insurance policies will contain free look clauses. This means that you can look the policy over when you receive it and cancel without penalty for a certain number of days. The clause protects you if you believe that the policy isn't what you want or doesn't suit you.



Q: Are there any claim forms to file with an HMO

  • A:



Q: Can I choose the doctors I want to see with a PPO

  • A:



Q: Can I see whomever I choose with an HMO

  • A:



Q: How are doctors associated with an HMO paid

  • A:



Q: Is there one best insurance plan

  • A:



Q: What are Health Maintenance Organizations HMOs

  • A:



Q: What are Preferred Provider Organizations PPOs

  • A:



Q: What are the basics with a fee for service plan

  • A:



Q: What are the most important points I should look for when purchasing an insurance policy

  • A:



Q: What can happen with a conditionally renewable policy

  • A:



Q: What if Im not satisfied with my care

  • A:



Q: What Is a Customary Fee

  • A:



Q: What is a look free clause

  • A:



Q: What is a noncancellable policy and how does it work

  • A:



Q: What is disability insurance

  • A:



Q: What is hospital indemnity insurance

  • A:



Q: What is long term care insurance

  • A:



Q: What is the cap on out of pocket expenses for a fee for service plan

  • A:



Q: What is the difference between basic and major medical coverage

  • A:



Q: What questions should I ask about a PPO before joining

  • A:



Q: What questions should I ask about an HMO

  • A:



Q: What questions should I ask related to Fee for Service Insurance

  • A:



Q: What type of coverage is available

  • A:



Q: Who is responsible for filing the claims with a fee for service plan

  • A:



Q: Why is my insurance company concerned if Im covered under any other plan

  • A:

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