Introduction

The choices you make while selecting and using health insurance may have an impact over the course of months or years of your life. Insurance choices can influence what doctors you see, what medications you take and how important medical procedures are covered.

Purposes

This article covers some of the basic topics related to selecting and using health insurance and can serve as an outline for a Member Services conversation you can have with a Navigator 24/7.

Table of Contents

Types of Health Insurance

Introduction

Different insurance 'types' represent different ways people use insurance to balance cost with healthcare options. Some people favor greater flexibility in how they select doctors or medicines and others may prioritize trying to keep their costs down. Insurance types such HMO, PPO and others listed below try to provide different insurance products to satisfy different consumer and employer preferences.

Health Maintenance Organizations - HMO

HMOs provide customers with a network of medical professions they can see for their care. For services to be considered for insurance coverage, customers need to work through their primary care doctor to see specialists. Primary care doctors coordinate much of the care covered by HMO insurance plans. Medical professionals outside of the network are not typically covered.

Point of Sales - POS

POS provide customers with a network of medical professionals they can contact for care. For services to be considered for coverage, customers need to work through their doctor to see specialists and coordinate care within the network. Some medical professionals outside of the network are covered but the customer may experience higher costs for that care when compared to in-network medical providers.

Preferred Provider Organization - PPO

PPOs are similar to the other "network" style plans described so far. PPOs provide customers with the option to see both in-network and out-of-network medical professionals but the monthly premiums tend to be a bit higher in exchange for that flexibility.

High Deductible Health Plan - HDHP

A high deductible plan may be applied to different types of insurance plans allowing people to deposit a portion of their pre-tax earnings in a special account dedicated to annual healthcare expenses.

Medicare

Medicare is Federally funded insurance available to those over the age of 65 and those under the age of 65 but with certain medical conditions. Medicare has 3 parts often referred to as Medicare Parts A, B, and D.

Medicare Advantage

Medicare Advantage, also known as Medicare Part C, is a bundled alternative to Medicare (ABD).

Medicaid

Medicaid is funded jointly by both state and Federal government and is available only under specific conditions to people with very limited income and assets.

Topics for Review

Medical Professionals

It can be helpful to develop and maintain a relationship with a doctor or medical practice over time. Finding medical professionals you trust and with whom you can communicate effectively can contribute to good healthcare. Working with the same doctors or practices over time may allow you to manage routine care more effectively and allow providers to spot changes in your health more effectively.

Primary Care Doctors

Some insurance types require customers to have a "Primary Care Physician" or PCP. The role of the PCP within an insurance-driven healthcare process is to help coordinate a patient's healthcare. For plans that require PCPs, customers see their primary care doctor for all routine care and get that doctor’s referral to see a specialist.

Specialists

There is a wide variety of specialists for different body parts and medical conditions. Some insurance plans require that your Primary Care Doctor first approve your visit to a specialist. That approval is typically called a referral. People who require long term specialty care may want to consider how each insurance "type" or "plan" handles the specialty care they require.

Tests & Lab Work

Doctors may request you to undergo some tests as part of your routine and preventative care. For treating specific illnesses or injury, you may require lab testing such as blood work or urinalysis. Some insurance companies work with specific networks of laboratories. It is important to check which laboratories are included in your insurance coverage.

Prescription Medication

Prescription medication can be an important part of disease treatment or prevention. The cost and availability of medicine should be considerations when choosing health insurance or treatment plans. Prescription medication habituation and addiction are important issues when considering medication plans.

Prescription Coverage

Not all types of insurance types or plans come with coverage for medication. Coverage may be called "Prescription", "Drug" or "RX" coverage. When selecting insurance plans, it is important to check if the insurance you are considering includes Prescription Coverage. If you are engaged in long term disease treatment or prevention that requires medication, you may wish to find out how much of your medications particular insurance programs will cover.

Vision Insurance

Vision insurance tends to be offered as an added feature at the time of health insurance enrollment. It is often provided by a different company than health insurance and tends to cover a portion of routine eye exams and a contribution towards the cost of eyeglasses.

Dental Insurance

Dental Insurance is often added to health coverage as at the time of enrollment and it is often provided by a different company than the general healthcare. Dental insurance tends to cover a portion of routine cleaning and checkups. Most dental insurance is limited to preventative and basic dental care and does not help defray the costs of complex dental issues.

Insurance Through Employment

Many people access health insurance through their employer. Some employers pay for a portion of the cost of health insurance as part of their benefits to employees. Some companies provide situations where their employees can have the cost of monthly health insurance premiums deducted from their paycheck before taxes are taken out, stretching their dollar a bit farther.

Insurance Marketplace

The "Insurance Marketplace" at Healthcare.gov allows US Consumers to buy health insurance directly from insurance companies if they cannot or don't want to access it through an employer. US residents in 32 states use the Insurance Marketplace and residents from 18 states and Washington DC use their own state level marketplace.

Medicare & Medicaid

State and Federally funded insurance are available under specific conditions. Access to some types of benefits may depend on age, income, medical conditions and state of residence.

What you stand to lose

Increased Costs

If you don't effectively select and use health insurance you may experience increased costs for your medical care and medicine in general. Small insurance mistakes, denied coverage and surprise billing can lead to extremely large medical bills and prolonged medical debt or bankruptcy.

Reduced Quality of Healthcare

If you cannot effectively select and use health insurance or you do not have health insurance, you may not get the preventative or diagnostic care you need when you need it. Delay in the detection or treatment of certain types of health situations can lead to serious illness and death.

Wasted Time & Effort

Treatment of illness or injury can be time consuming when considering the research, appointments, travel, paperwork and follow up. Small health insurance or care provider issues can grow into time consuming hard-to-resolve situations lasting months.

Emotional Distress

Navigating complex healthcare issues with financial impacts can cause additional emotional distress even when you are feeling well and can be especially hard to manage when you are sick or undergoing treatment for illness.

Member Services

Noble Navigators provides guidance, direct action and ongoing support services for more than a dozen important life situations, including providing care for others. If you or someone you know needs assistance, please contact Noble Navigators 24/7 for live assistance

Behind the Scenes

It is important that Consumers make informed decisions when it comes to selecting and using health insurance. These choices have long term consequences regarding choosing doctors and the availability of medication.

Key Terms

Premiums

The recurring fees you pay to the insurance company, typically each month.

Deductibles

The amount of medical expense you are expected to pay each year before your insurance starts to cover your medical expense (for example $1,000 per year).

Co-pay

Your fixed portion of the bill for some regular doctor visits (for example $30 per visit).

HSA - Health Savings Account

A way for people to deposit some of the money they earn into an account dedicated to annual medical expenses to reduce their tax liability.

Coinsurance

The percentage of future bills your insurance company expects you to pay (for example 19%).

Network

A group of medical providers for which a particular insurance plan will cover services. As compared to "out-of-network" providers for which services may not be covered.

Open Enrollment

The seasonal period of time each year during which consumers may more easily enroll in health insurance.

Primary Care Physician

Some insurance plans require you to begin your medical care through a single doctor who will be your "primary care physician" or PCP, who will handle routine care and may refer you to specialists for other needs.

Referrals

A "referral" means that the primary care physician believes that additional medical diagnosis or treatment is necessary and within the guidelines of the insurance company. A referral puts the decision to see a specialist in the hands of the primary care physician.

Pre-approval

Some insurance plans require that procedures and other forms of care are approved by the insurance company in advance in order to qualify to be covered by the insurance.

Medicare A

Medicare A is "Hospital Insurance"

Medicare B

Medicare B is "Medical Insurance"

Medicare D

Medicare D is for "Drug Coverage

Medicare Advantage

Medicare Advantage also known as Medicare Part C, is a bundled alternative to Medicare (ABD).

Preventative Care

Healthcare designed to prevent or substantially delay the onset of particular types of disease or other negative health outcomes.

Habituation

The process where a patient's body becomes acclimated to medication and more medicine is required to produce the same intended effect.