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Individual | Group | Medicare
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HMO | PPO | H.S.A. | Child Only | Maternity | Foreign Travel | Student | Immediate / Short-term | Dental
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Read the defintions below for common Health Insurance terms to learn more about your managed care and health care options. Compare HMO vs PPO plans as well as many other health insurance options. If you have any questions about these or any other Health Insurance terms or managed care options, we can provide assistance to ensure your unique health insurance needs are met. Call, email, or submit our Health Questionnaire today.
Coinsurance
The amount you may be required to pay for services after you pay any plan deductible.
Copayment
The amount you pay for some medical services according to your health plan details. A copay does NOT usually go towards meeting your deductible or coinsurance amount.
Credible Coverage
When you have been covered by group insurance (or some other types but not individual insurance) for the past 18 months with no break in coverage for greater than 63 days, you are said to have credible coverage. You will be asked to prove credible coverage by providing a Credible Coverage Statement from each carrier that has covered you in the past 18 months. Once you prove credible coverage, individual insurance carriers will remove the pre-existing period from your coverage.
Deductible
The amount you must pay for some medical services according to your health plan details before the carrier begins to pay. Lab, x-ray, office procedures, outpatient surgery, hospitalization and emergency department benefits usually require you to meet your deductible first.
Formulary
A list of generic and brand names drugs that are covered under a specific health plan. Usually there are NO benefits for drugs not on the formulary.
PPO – Preferred Provider Organization
A PPO is an insurance plan which contracts with one or more groups of health care providers including doctors, hospitals, clinics, labs, etc. to provide you with services at a discounted price. As a member, you will receive better benefits when you choose to seek services from a network provider. However, benefits will be available for non-network services as well. You will NOT be required to select a Primary Care Provider or to obtain a referral prior to seeing a specialist.
A PPO has a finite amount of money they are at risk for to provide your care called the Lifetime Maximum. Frequently, PPOs will limit certain services on an annual basis such as the number of physical therapy sessions.
The underwriting process will review your current health status and determine if you are appropriate for membership. If you have pre-existing conditions you may experience an increase in your rate, a waiver / rider which will eliminate coverage for a specific condition or a denial of membership. In addition, there may be a waiting period before pre-existing or other conditions such as some surgeries may be covered.
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H.S.A.
A Health Savings Account is a pre-tax savings account that works in conjunction with a High Deductible Health Plan (HDHP) and is authorized under IRS regulations (see www.irs.gov). To qualify for an H.S.A. you must be currently insured under a high-deductible health insurance plan, have no other coverage (coverage for accidents, disability, dental, vision or long-term care do NOT disqualify you), NOT be enrolled in Medicare and NOT be claimed as a dependent on another person’s tax return.
The insurance part: Usually the high deductible plan is a single deductible for either an individual or a family. Once you have met the deductible in any one year, one of two things happens: 1) you may select to have a coinsurance period where you and the carrier share the bills (typically 20% for you) until a specific amount of money is spent by you, OR 2) you select NO coinsurance and at that point the carrier pays the remainder of the health care expenses that year that qualify as benefits under your plan.
The H.S.A. part: You are allowed to put pre-tax money into a savings account each year. The amount allowed depends upon the deductible you select and/or the maximum allowed by the IRS. The money can be drawn out and remains tax free as long as it is used for medical, dental, vision or other expenses allowed by the IRS (see www.irs.gov). The money will earn interest. You can select from many banks within our country that will provide you with the account. Each bank has their own unique terms such as annual minimum deposit, annual or monthly charges, optional checks or debit cards. The bank is responsible to report the money you deposit and withdraw annually to the IRS. They are NOT responsible to report the reason for the withdrawal. You must maintain records to qualify your withdrawals should you be asked to do so. The money in the H.S.A. is yours forever…as you grow older, move to a new employer or a new state.
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HMO – Health Maintenance Organization
An HMO takes a financial risk to provide you with specific medical services. HMOs have no lifetime maximum. The underwriting process will review your current health status and determine if you are approved for membership. If you are accepted by an HMO, there are NO waiting periods, and NO pre-existing condition waivers / riders.
HMOs generally have a unique provider network. You must use the physicians and other providers within the network. There are NO benefits for services provided outside the network other than emergency care. You will be required to select a primary care physician. A referral to a specialist may be required. This close relationship with providers allows HMOs to unite with their providers in managing your care. HMOs are generally less expensive than PPOs.
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Child Only Coverage
A carrier or plan that offers health care coverage for children without requiring an adult to be covered on the same policy. Some times the carrier will require a newborn to have had their 2-month check-up or more prior to submitting an application. Newborn babies may be very expensive on Child Only coverage until they reach their first birthday.
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Maternity Coverage
A plan that offers benefits for non-emergency care related to pregnancy and childbirth. Most plans will provide limited coverage for childbirth emergencies only. A plan that provides maternity benefits is designed to cover maternity and delivery care the same as any other illness. In the state of Texas there are very few individual health insurance plans or discount only plans that offer maternity coverage. You may be require to be on the plan for a period of time prior to the delivery.
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Foreign Travel
These plans are designed to cover people traveling from their country of origin (Americans and Non-Americans) for a period of time. Foreign travel plans offer many additional benefits such as transportation back to your home country should you become ill. Many US health insurance plans do NOT cover non-emergency health issues outside the US or will place a time period after which they will not provide any coverage outside the US. It is always wise to purchase foreign travel insurance.
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Student Health Insurance
This coverage is designed for college students of all ages. Some plans will even extend their coverage if you take a semester off. The premium is low and can be paid annually or biannually. Be careful though, the benefits are typically very limited.
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Immediate Coverage / Short Term
This insurance is designed for people who are without current health insurance and wish to be covered immediately. Coverage can begin as early as one minute after midnight of the day it was purchased. Coverage is available to people of all ages and can be purchased on a monthly basis (stopping any month) for up to 12 months. This insurance is usually less than PPO individual insurance since the period of risk is so greatly reduced. Pre-existing conditions may not be covered.
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Dental Discount Plans vs. Dental Insurance
Dental insurance plans provide the following : approximately 50% discount on dental services from a general dentist, an additional approximately 20% of the bill is paid by the insurance carrier and you are left with approximately 30% to pay. Dental insurance plans usually have waiting periods for services and an annual maximum amount that they will pay for your dental care. Although the price varies between the plans, a single adult is approximately $20 to $35 a month and a single child is approximately $10 to $35 a month. Individual dental insurance plans require you use dentists in their network.
Discount dental plans are plans that offer you a discount on your dental care of approximately 50%for general dentists. They do NOT pay any additional money toward your services. Typically they require that you pay the dentist for services given on the day of service by credit card, cash or check. Typically there are NO waiting periods and no rules about annual maximum services. Discount dental plans cost approximately $8 to $10 a month for a single person and $9 to $12 a month for a family. You will be expected to pay for a year of coverage at one time. Discount dental plans require you use dentists in their network.
I suggest you look at the discount plans first by going to my website and clicking on the box with the two smiling girls. You will be asked for your zip code. If you live in an affluent area, you may find that dentists in neighboring areas are more likely to take the discount plans. So be sure to ask for dentist in a large area like 30+ miles. I suggest you search through the dentists available first. Then once you find a dentist you like, you will notice the names of the plans they participate in listed by their name. Call their office to ensure they still accept the discount plan. THEN, click on the plan to search through the benefits. You can purchase the plan on-line and receive your policy, pricing / discount information and dental cards electronically.
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