Essential Facts About Health and Dental Insurance

Most people obtain their medical and dental insurance via their employer or via their spouse’s employer. However, when someone is going through a difficult transition such as loosing your job or divorce, medical coverage is often neglected. It is important that you know your options so that you can keep yourself and your family healthy. Medical coverage is not something that should be taken lightly, especially if you have children or if you have a history of medical problems. Even if you are healthy, an unexpected emergency can leave you in financial crisis. Below we describe several services that can help you when looking for an individual medical plan, a family medical plan, or children’s medical plan as well as your options when going through transition periods such as switching jobs or loosing your work medical coverage.

Getting Individual or Family Medical Coverage:

In the case where your employer does not offer a medical plan, we recommend that you review the following tips, and visit the following online source when shopping for a plan. eHealthInsurance will provide you with side-by-side quotes for easy comparison of rates and terms.

Tips when purchasing individual coverage:

• Make sure the policy covers large medical costs.
• Make sure you read and understand the policy, the last thing you need is to be surprised with what your policy doesn't cover.
• What is covered in the policy?
• What is not covered in the policy?
• Is there a waiting period before coverage takes effect?
• Look for a "Free Look" clause, most companies allow you up to 10 days to review the policy after it has been received. If you feel the policy is not right for you, they refund your premium.

We recommend that you become informed by reading our section types of medical plans located at the end of this article, so that you can choose the best option for yourself or family. We have also put together a list of questions that you should ask the provider when considering one of the following medical plans: FFS, HMO, PPO, and Federal programs (Medicare, Medicaid, and SCHIP).

Shopping for Medical Plans:

eHealthInsurance features one of the largest selections from the leading medical plan providers. They offer instant quotes with side-by-side comparisons to help you make your decision. They offer a toll free phone number, e-mail, and chat-room where you can get help and advice from representatives and licensed professionals. Getting quotations and applying for medical coverage is very easy. All you have to do is provide your zip code, birth dates of family members to be insured, compare plans and prices, and apply online. They provide quotes for full medical, dental, and short-term coverage. You will also be able to find very competitive rates. We highly recommend that you take advantage of their service.

DentalPlans.com features a large selection of national and regional plans. They offer instant quotes with side-by-side comparisons to help you make your decision. They have a toll free phone number and e-mail, where you can get help and advice 24-hours a day from one of their dental plan experts. In order to get a comparison of the different plans, all you have to do is enter your zip code. They provide you with an instant list of available plans, quotes, benefits for general and specialists dental services, as well as number of participating dentists within 50 miles of your area. We highly recommend that you review their plans.

Other Sources for Medical Coverage:

In some cases you might also be able to get group medical coverage through membership in a labor union, professional association, religious organization, or other membership organization. We recommend that you check with the organizations where you are currently a member. You should compare the group-discounted rates that are offered by these organizations with the options available through EhealthInsurance.

Child Medical Plan:

InsureKidsNow is an excellent online resource to visit when looking for child medical coverage. Keeping your children healthy has to be your highest priority. There should be no reason why your children should be without medical coverage when there are so many programs available to help you. All states have programs designed to help families of all incomes provide medical coverage for their children. This online resource is a nationwide campaign for raising awareness about SCHIP (State Child Health Insurance Programs), which helps provide free or low cost medical coverage to children from birth to 18 years of age. Children that have medical coverage tend to be sick less often because they receive the necessary immunizations, preventive care, and treatments for common childhood illnesses such as ear infections, asthma, etc. All states provide medical coverage that take care of visits to the doctor, prescription medicines, hospitalizations, and much more at little or no cost to you. Some states also include the cost of dental care, eye care, and medical equipment. The income levels for eligibility to these programs at the reduced cost are listed on each states web site. You should fill out an application even if you are unsure if you qualify for the reduced cost. Families that earn more than the limits can also buy medical coverage at the full cost. Depending on your income and state, some will offer medical coverage to the entire family. We recommend that you visit them online, so you can see what programs are available in your state.

College Students Medical Plan:

Most parents’ medical plans will cover children up to ages between 20 and 24 as long as they are still in school. You should check with your provider. If your child has lost coverage from the SCHIP state program because they have reached 19 years of age, but they are attending or will be attending college, you should ask regarding the medical plans offered by their college. Colleges are usually able to offer medical plans at reasonable prices because they can get group rates, and they are sometimes subsidized by the schools. It is also common for colleges to have on-campus medical centers that offer care at free or little cost to the students. There should be no reason why your child does not have medical care coverage while they are away at college. A serious illness or injury can have long-term financial consequences for your self and your child. You will also have the peace of mind knowing that your child will have no reason to hesitate going to the doctor if they don’t feel well.

Transition Period:

If you are going through a transition period where you have lost your medical coverage because you have lost your job, or you were covered through your spouse’s employer and are now divorced or widowed, the Federal law COBRA is an option that is available to you. The Federal law COBRA(Consolidated Omnibus Budget Reconciliation Act of 1985) makes it possible for most individuals to continue their coverage for a period of at least 18 months, at a higher premium. You will be responsible for paying the entire cost of the plan, including the portion that your employer was paying and up to an additional 2% in administration fee. Your employer should contact your provider administrator within 30 days of you loosing your eligibility for coverage. In the case of divorce, widowed, or child loosing dependent status you should contact the provider within 60 days. Always keep in mind that your job search could take longer than expected, so you should give COBRA strong consideration. The law is applicable for the following cases:

• If your coverage was provided through your spouse’s job, but now you are widowed or divorced.
• If you work for a business with 20 or more employees and leave your job, are laid off or loose eligibility due to reduction of hours.
• If you were covered through your parent’s group plan while you were in school.
• If you have lost dependent coverage due to retirement, Medicare, or an employer’s bankruptcy.

HIPAA (Health Insurance Portability and Accountability Act of 1996) is also known as the Kassebaum-Kennedy Act. It allows you to maintain your medical coverage if you are switching from one provider to another. However, it does not offer protection when switching between a group plan to an individual plan. The main objective of this law is to allow you to move from one job to another without fear that the new provider will claim a medical condition as pre-existing and refuse to cover it. Your new provider cannot refuse coverage, if you had a creditable provider for the prior 12 months, and no lapse of coverage for a period of 63 days or more. Your new medical plan would need to cover all medical problems as soon as you are enrolled in the plan. You must not let your coverage lapse for more than 63 days in order to keep your coverage continuous. This is also where COBRA can help if you are between jobs because you can continue your coverage without any lapse. Please visit the official web page by clicking the link above for further details.

Types of Medical Plans:

Fee-For-Service (FFS) or Traditional Plan:

This plan is the traditional medical plan. The provider only pays part of your doctor and hospital bill; however, it provides the widest choices when it comes to doctors and hospitals. You are able to choose any doctor or hospital that you want as well as change doctors as often as you like. This plan has a premium (monthly fee), and a deductible (amount of money) that must be paid each year before the payments begin. Once your deductible is paid, you share the bill with the provider. For example: you pay a copayment of 20% and the provider pays 80%. In this type of plan, you are responsible for keeping track of your medical expenses. Most of the fee-for-service plans have a cap. Once you have reached a certain amount with your deductible and your copayment, the provider pays the full amount of items covered by the policy in excess of the cap. Reaching the cap does not exclude payment of the monthly premium.

There are two kinds of coverage, basic and major medical plan. The basic covers the costs of a hospital room and care while in the hospital. It also pays towards the surgery and covers some of the hospital services and supplies, such as x-rays and medicine. The major medical plan would take over where the basic coverage would stop covering, such as long, high-cost illnesses or injuries. When both plans are covered under one plan, it is called a comprehensive plan.

One more thing to understand regarding the Fee-For-Service plan is the customary fee. The insurer will only pay what they consider reasonable for a particular service based on normal charges in your area. You are responsible for any additional charges above the reasonable charge amount. In order to avoid any additional costs, you should always ask your doctor to accept the provider's payment as full payment, or find one that will.

Fee-For-Service check list:

• Talk to someone you know that is on the plan and ask them how they feel about the service.
• What is the monthly premium for individual or family rate?
• What is the deductible?
• What is the copayment rate?
• Is there a lifetime maximum cap for the insurer, where they would stop covering expenses?
• What services are limited or not covered, such as prescription drugs, home care, etc?
• Whether they offer a comprehensive plan?

Health Maintenance Organization (HMO):

HMOs are comprehensive medical plans that cover visits to the doctor, tests, hospitalization, surgery, emergency care, and therapy for a monthly premium. The choices of doctors, and hospitals are usually limited to the ones that have an agreement with the HMO. There is usually a co-payment with each Doctor’s visit, purchasing medicine, and hospital emergencies. HMOs normally take care of your preventive medicine needs such as immunizations, office visits, physicals, and regular checkups for your whole family. The medical costs for HMOs are normally lower than with Fee-for-service plans. HMOs also don’t require claim forms for visits to the doctor or hospital care. Usually, HMOs require you to pick a primary care physician that will take care of your basic medical care needs, and your primary care physician will refer you to a specialist when needed. Most HMOs require your doctor’s referral for you to see a specialist.

HMO check list:

• Talk to someone you know that is on the plan and ask them how they feel about the service.
• How many doctors can you choose in your area, and are all of them accepting new patients?
• Is it easy to change primary care physician?
• What is the process for getting a referral to a specialist?
• What is the normal wait for regular check up appointment?
• What is the process for handling emergencies?
• Does the HMO have any limits on medical tests, surgeries, mental care, or home care?
• Are the locations of the medical facilities, hospitals, and emergency centers convenient to you?
• What are the monthly charges?
• What are the co-payments for doctors’ visits, prescription drugs, hospitalization, surgery, or other services?

Preferred Provider Organization (PPO):

PPOs are a combination of fee-for-service and HMOs. PPOs are like the HMOs in that there is a limited number of doctors and hospitals to choose. Most of your medical bills are covered when you use the preferred or network services. Like with HMOs, you will usually have to choose a primary physician, and doctors’ visits normally require a co-payment You may be required to pay a deductible or copayment for some services. Unlike HMOs, you can go to doctors or service providers that are not preferred or network, but you will have to pay a larger amount out of pocket as well as fill out the claims form.

PPO check list:

• Talk to someone you know that is on the plan and ask them how they feel about the service.
• How many doctors can you choose from in your area, and are all of them accepting new patients?
• What is the process for getting a referral to a specialist?
• What is the normal wait for regular check up appointment?
• What is the process for handling emergencies?
• Does the PPO have any limits on medical tests, surgeries, mental care, or home care?
• Are the locations of the medical facilities, hospitals, and emergency centers convenient to you?
• What are the monthly charges?
• What are the CO-payments for doctors’ visits, prescription drugs, hospitalization, surgery, or other services?
• What are the charges for doctors’ visits, hospitalization, and other services outside the preferred list or network?

Federal Programs

If you can’t afford individual medical coverage, there are several federal sponsored programs that can help you as long as you meet their eligibility criteria.

Medicare is a program for people age 65 or older. It is also available to younger people with disabilities. If you wish to get further information about this program please visit the official web page.

Medicaid is a program for low-income individuals and families. If you wish to get further information about this program please visit the official web page.

SCHIP is a program for parents that are not eligible for Medicaid, but it is too difficult to afford individual medical plans. We also recommend that you visit InsureKidsNow were you can find further details on the programs offered by your state.

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