Group Health Overview Group Health insurance is similar in form to individual
health insurance. The primary differences are the conditions under which a person may apply
and the requirements for acceptance. Before applying through a group a person must satisfy the waiting
periods and employment requirements of the group. However, once an application
can be made, the conditions for acceptance are usually less strict than with an
individual policy. Also, certain protections under the law are available for members of group policies that are
not available to owners of individual plans.
What It Is Not Group Health insurance is not necessarily a guarantee of
coverage. There are many rules, set forth by federal and state law, which must be followed closely in order to
obtain coverage. An insured always must make certain that he or she has followed the law, to the letter, in order to
provide maximum protection. In other words: Do not assume you have coverage, talk to a qualified agent!
Evaluating Your Needs
When evaluating your needs you should keep several things in mind:
Not all health plans will let you go outside the network, if this is important to you make sure that your plan has an "out-of-network" benefit. Check for coverage of routine medical care. Not all plans cover "routine checkups" or cover them only in small amounts. Check the drug benefits. Forty percent of the cost of medical care is for drugs. Some health plans use a formulary system to determine which drugs they will pay for. Make certain that this formulary is extensive and that your doctor is willing to prescribe off of the formulary if necessary. Product Definitions Preferred Provider Organizations (PPOs) are one step over the
managed care border. PPOs have made arrangements for lower fees with a network of health care providers.
PPOs give their policyholders a financial incentive to stay
within that network. With a PPO, you can refer yourself to a specialist
without getting approval and, as long as it is an in-network provider, enjoy the
same co-pay. Staying within the network means less money coming out of your
pocket and less paperwork. Preventive care services may not be covered
under a PPO. Health Maintenance Organizations (HMOs) are the least
expensive, but also least flexible type of health plan. They also tend to
be geared more toward members of group plans than individuals. In
exchange for a low co-payment (or sometimes no co-pay at all), low premiums and
minimal paperwork, an HMO requires that you only see its doctors, and that you
get a referral from your primary care physician before you see a specialist. If
you can still pick up the phone, you will probably need to get clearance before
you can visit the emergency room.. Point-of-Service (POS) are similar to PPOs, but they introduce the gatekeeper, or Primary
Care Physician. You will need to choose your PCP from among the plan s network of
doctors. As with the PPO, you can choose to go out of network and still
get some kind of coverage. In order to get a referral to a specialist,
though, you usually must go through your PCP. You can still choose to
refer yourself, but it will mean more hassles and more money coming out of your
pocket. Fee-for-service or indemnity coverage was the norm. Under this
type of health coverage, you have complete autonomy when it comes to choosing
doctors, hospitals and other health care providers. You can refer yourself to
any specialist without getting permission, and the insurance company does not
get to decide whether the visit was necessary. |