Overview on USA Healthcare Insurance - Understanding a Health Insurance Plan

Understanding a Health Insurance Plan

Understanding the basics about health insurance can be a very daunting task. In a developed country like USA, there are numerous health insurance products and services available and choosing a policy cover that meets or satisfies an individual’s requirements can be even more confusing. Invariably, an individual has to compromise in certain areas, as he/she may not get a policy satisfying his/her requirements. Whether it is cost, variety of products/services covered or access to the medical professionals of his/her choice, it is quite rare to come across the most perfect plan.

What are the most important features in a Health Insurance Plan?

In choosing a health insurance plan, an individual should decide as to what is most important to him/her. All plans have tradeoffs. The following points should be analyzed before purchasing a health insurance product/service:

• Is the health insurance policy being availed or considered by the individual comprehensive in nature? How much comprehensive should the coverage of healthcare services be while availing such healthcare facilities?
• What is the opinion regarding limits imposed on an individual’s choice pertaining to doctors or hospitals?
• What is the reaction when a primary care doctor refers an individual to medical specialists for additional care?
• Is it convenient for availing the healthcare facilities being provided by the healthcare insurance cover?
• How important is the cost of healthcare products and services being offered under the insurance cover?
• What is the budgetary allocation by an individual for spending on health insurance premiums and other healthcare costs?
• What is the reaction or feeling regarding maintenance of medical receipts and filing claims?

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An individual or a prospective customer may also consider and analyze as to whether the services being offered under the health insurance plan meets his/her needs. Call the plan for details about coverage if you have questions. Such circumstances include:

• Changes in the course of life being considered by an individual such as – getting married or retiring
• Chronic health conditions or disabilities that an individual may be suffering from including his/her dependant family members
• Care for the elderly, aged including senior citizens.
• Frequent relocation opportunities
• Job requires constant travel including job postings in remote locations across USA.

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Points to be borne in mind while purchasing a Health Insurance Cover

Some tips to be followed when shopping for individual health insurance are enlisted below:

• Shop for health insurance products and services carefully. Individual health insurance policies differ widely in coverage and costs. It is always recommended to contact different insurance companies or ask the insurance agent to showcase different healthcare policies from several insurers so that comparative study of the existing or available policies can be made.
• Make sure that the individual health insurance policy provides protection from inflated and exorbitant medical costs. Read and understand the policy. Make a note of fine-prints. Make sure that the insurance policy provides the kind of coverage that is appropriate and customized for him/her. Surely no individual wants to be caught up with unpleasant surprises when he/she falls sick or hospitalized.
• Make a note to check what is stated in the healthcare insurance policy cover i.e. the date from which the policy will begin reimbursement (as certain policies have a waiting period before coverage begins). It is recommended to make a note of the list of medical facilities covered or excluded from coverage. 

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• Make sure there is a "free look" clause incorporated in the policy. Most of the health insurance companies provide at least 10 days to go through the policy after receiving it. If an individual does not feel satisfied with the services being provided under the policy cover as well as it does not meet your requirements, an individual has the liberty to return it, if he/she so desires and have the premium refunded.
• Beware of single disease insurance policies. There are some polices that offer protection for only one disease for eg. cancer. It is always advisable to check as to what protection is being provided to an individual by the insurance product or service.
• Before purchasing any health insurance policy, it is recommended to make sure that the individual is well-aware about what healthcare facilities would be payable and for what reimbursement would not be provided.

What Health Insurance Plan Benefits Are Offered?

Most health insurance plans provide basic medical coverage, but such details need to be carefully examined before purchasing a suitable health cover. A health insurance plan that is good for an individual may or may not be the best plan for another individual. For considering the health insurance policies, the following parameters should be considered as enlisted below:

• Physical examinations and health screenings
• Medical care provided by specialists and super-specialists
• Hospitalization, ICU care and emergency care facilities
• Prescription drugs
• Vision care
• Dental services
• Care and counseling for mental health
• Services for drug and alcohol abuse
• Obstetrical-gynecological care and family planning services
• Ongoing care for chronic (long-term) diseases, conditions or disabilities.
• Physical therapy and other rehabilitative care
• Domiciliary healthcare, nursing home and hospice care.
• Chiropractic or Alternative health care, such as Acupuncture, Ayurveda, etc.
• Experimental treatments
• Health screenings provided in case of women such as breast examinations and Pap smear tests
• Health insurance coverage for children and infants
• Coverage of dependant family members

What Are the Health Insurance Costs?

Any health insurance plan will cover every expense that is incurred for selling the same to the public i.e. the actual product/service cost, marketing, advertisement, sales, logistics, product promotion, branding, professional fees, underwriting costs, actuary fees, advisory fees etc. costs are incorporated in any policy cost before being sold to a prospective customer. To get a true picture of what costs will be incurred under each plan, the individual needs to give importance to the amount to be paid as premium for purchasing health insurance products/services and other associated costs. Some of these costs have been enlisted below:

• Are there deductibles that must be paid by an individual before the health insurance begins to cover the incurred medical costs?
• After having fulfilled health insurance deductible, what part of healthcare costs are reimbursed under the plan?
• Does the amount vary by the type of product, service, doctor, or health facility used by an individual?
• Are there co-payments to be paid for certain services under the plan such as physician’s visits?
• If an individual decides to utilize the services of doctors outside a healthcare plan's network, how much more would the concerned policyholder would have to pay so as to avail the desired healthcare facilities?
• If a health insurance plan does not cover certain services or facilities that an individual feels it necessary that would be required at a later stage or in future, how much extra payment would have to be made to avail such facilities?
• Are there any limits or caps on how much would be reimbursed in case of major illnesses or accidents? In case of major illnesses, how much amount needs to be contributed by the concerned policyholder to enjoy the healthcare benefits provided under the plan?
• Is there any upper limit on how much the plan will pay for the concerned policyholder’s expenses pertaining to medical care in a year or over a lifetime?

A single hospital stay for a serious medical condition could cost hundreds of thousands of dollars. An individual cannot make any forecast in advance regarding his/her healthcare needs for the forthcoming year. But definitely the concerned policyholder can guess what services would be required by himself/herself including his/her family dependants. It is important for any policyholder or a prospective customer to figure out what the total costs to the family would be for the services incurred under each health insurance plan.

Location of Healthcare Services

The following points need to be given due weightage:

• Where will the healthcare facilities be availed by the concerned individual?
• Are these healthcare facilities near the place of residence or workplace?
• How does the insurance plan take care of healthcare services when an individual is living far away from his/her home?

Limitations on Healthcare Products and Services

Each and every healthcare plan has some limitations. The services being offered by each health insurance plan needs to analyzed judiciously as follows:

• What healthcare products and services are not covered under the plan? What are the exclusions under the plan?
• What healthcare products/services are only partially payable under the policy?
• Is it a good match between what is being provided and what would be required in the future based on the policyholder’s assumptions? For example, if an individual is suffering from a chronic ailment, is there a special program for that illness? 
• Will the plan provide the medicines, drugs and equipments etc that may be eventually needed?
• A few indemnity and managed care plans cover treatments that are experimental in nature. The concerned customer should clarify from the insurance agent regarding the classification of experimental or unscientific treatment. On what basis is the classification of experimental treatment made?
• Incase, if a policyholder disagrees with a Insurance company’s decision delivered regarding the claims reimbursement pertaining to an individual’s medical care or coverage, what steps could be taken? What action could be initiated for further course of action regarding disagreement in the aforesaid matter?