Choosing a Health Insurance Plan

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Affordable Care Act

The 2010 Affordable Care Act puts in place comprehensive health insurance reforms that will roll out over several years. Most changes will take effect by 2014; a timeline of the provisions is available. The law is intended to lower health care costs, provide more health care choices, and enhance the quality of health care for all Americans. Major provisions affecting consumers include:

  • Coverage for seniors who hit the Medicare Prescription Drug "Donut Hole," including a rebate for those who reach the gap in drug coverage;
  • Expanded coverage for young adults, allowing them to stay on their parents' plan until they turn 26 years old;
  • Small-business tax credits to help these companies provide insurance coverage to their workers; and
  • Providing access to insurance for uninsured Americans with pre-existing conditions.

For more information about the new law, go to healthcare.gov.

Group Policies

Many consumers have health care coverage from their employer. Others have medical care paid through a government program such as Medicare, Medicaid, or the Veterans Administration.

If you have lost your group coverage from an employer as the result of unemployment, death, divorce, or loss of "dependent child" status, you may be able to continue your coverage temporarily under the Consolidated Omnibus Budget Reconciliation Act (COBRA). You, not the employer, pay for this coverage. When one of these events occurs, you must be given at least 60 days to decide whether you wish to purchase the coverage.

Some states offer an insurance pool to residents who are unable to obtain coverage because of a health condition. To find out if a pool is available in your state, check with your state department of insurance. 

Medicare and Medicaid

There are also health insurance programs for people who are seniors, disabled, or have low incomes.

  • Medicaid provides health insurance for people with low incomes, children, and pregnant women. Eligibility is determined by your state.
  • Medicare provides health insurance for people who are 65 years or older, some younger people with disabilities, and those with kidney failure.

Most states also offer free or low-cost coverage for children who do not have health insurance. Visit insurekidsnow.gov or call 1-877-KIDS-NOW (543-7669) for more information.

Healthcare Plans

When purchasing health insurance, your choices will typically fall into one of three categories:

  • Traditional fee-for-service health insurance plans are usually the most expensive choice. But they offer you the most flexibility when choosing healthcare providers.
  • Health Maintenance Organizations (HMOs) offer lower co-payments and cover the costs of more preventative care, but your choice of healthcare providers is limited. The National Committee for Quality Assurance evaluates and accredits HMOs. You can find out whether one is accredited in your state by calling 1-888-275-7585. You can also get this information as well as report cards on HMOs.
  • Preferred Provider Organizations (PPOs) offer lower co-payments like HMOs but give you more flexibility when selecting a provider. A PPO gives you a list of providers you can choose from.

WARNING: If you go outside the HMO or PPO network of providers, you may have to pay a portion or all of the costs.

When choosing among different health care plans, you'll need to read the fine print and ask lots of questions, such as:

  • Do I have the right to go to any doctor, hospital, clinic or pharmacy I choose?
  • Are specialists such as eye doctors and dentists covered?
  • Does the plan cover special conditions or treatments such as pregnancy, psychiatric care and physical therapy?
  • Does the plan cover home care or nursing home care?
  • Will the plan cover all medications my physician might prescribe?
  • What are the deductibles? Are there any co-payments?
  • What is the most I will have to pay out of my own pocket to cover expenses?
  • If there is a dispute about a bill or service, how is it handled? In some plans, you may be required to have a third-party decide how to settle the problem.

Appealing Health Insurance Claims

If your health insurer has denied coverage for medical care you received you have a right to appeal the claim and ask that the company reverse that decision. You can be your own health care advocate. Here's what you can do:

Step 1: Review your policy and explanation of benefits.
Step 2: Contact your insurer and keep detailed records of your contacts (copies of letters, time and date of conversations).
Step 3: Request documentation from your doctor or employer to support your case.
Step 4: Write a formal complaint letter explaining what care was denied and why you are appealing through use of the company's internal review process.
Step 5: If the internal appeal is not granted through step 4, file a claim with your state's insurance department.