Health insurance overview
Comparing health plans
Employers decide on coverage and costs
A health plan needs to fit your health needs and your pocketbook. If you get insurance at work, your employer selects the health plan choices available to you. However, understanding how insurance works will help you make the best use of your benefits.
If you are buying insurance on your own, you may need to sort through an alphabet soup of plan types - from PPOs to HMOs. Although major medical health plans typically cover an array of health care - from doctor visits to hospital care - benefits can be delivered in different ways and with different price tags.
Managed Health Insurance (Managed Care)
Most people are covered by some form of managed care. These plans control health care costs by tying insurance policy benefits to a network of "preferred providers" such as doctors and hospitals that contract with or are employed by the insurance company. Managed care lowers your costs. Types of managed care include:
- Exclusive Provider Organization (EPO)
One of the newer types of managed care, an EPO will only pay for care received from a medical provider within the EPO provider network. Although exceptions may be made for emergencies, generally, you must choose a primary care physician or medical group within the network. Your primary care physician will make referrals to specialists when necessary.
- Preferred Provider Organization (PPO)
PPO insurance plans sign contracts with selected hospitals, physicians, and other providers who agree to provide services at a discounted rate. If you use doctors outside this "network,'' you will generally pay more out-of-pocket. Prior approval from the insurance company may be required before you get services from a non-preferred provider. If you do not get approval in advance, the insurance company may refuse payment.
- Managed Care Organization (MCO) or Health Maintenance Organization (HMO)
These insurance plans usually make you choose a primary care provider from a list of in-network providers. Your primary care provider is responsible for managing all of your health care. Except for emergencies, if you need care from another provider, your primary care provider may need to give you a referral. This means the insurance company does not usually pay for treatment from a non-contracted provider.
- Point of Service Plans (POS)
These insurance plans share features of PPO and HMO insurance plans. They require you to select a primary care provider from a list of in-network providers. Your primary physician may refer you to a doctor that is outside the network but you will pay more of the cost.
This type of insurance plan pays a percentage (such as 80%) of your covered medical care after you pay your deductible. These plans provide the most flexibility - and typically cost the most - because you have the freedom to choose your doctor, specialist, or hospital with few if any limitations.
Health Savings Accounts (HSA) pair higher-than-average deductible plans with a tax-exempt health savings account. You can make tax-free contributions to the account and use the money to pay for certain medical expenses or even save for care in future years. However, premiums for health insurance (individual or group) can't be paid from HSAs. Insurance companies will identify which of their individual plans qualify for HSAs. Learn more at: http://www.irs.gov/pub/irs-pdf/p969.pdf
Limited Benefit Plans for particular services or diseases
- Basic Hospital Expense plans: These plans cover a specific number of days of continuous inpatient hospital care and specific outpatient hospital services.
- Basic Medical-Surgical Expense plans: These plans only pay for medically necessary surgery costs and a specific number of hospital care days.
- Hospital Confinement Indemnity plans: These plans pay a fixed amount for each day that you are in the hospital.
- Accident-Only plans: These plans pay for death, dismemberment, disability, hospital, and medical care caused by an accident.
- Specified Disease plans: These plans pay for diagnosis and treatment of a specific disease or diseases, such as cancer.
- Other Limited plans: You may purchase insurance covering only dental or vision or other specified care.
Questions to ask when comparing plans
Here are some questions you might ask to help you compare health insurance plans if you are buying individual insurance or have a choice of employer group plans.
- What will your premiums cost? How much is the deductible, co-pay, or co-insurance? How often will you have to pay the deductible or co-payment (yearly or each time you use a service)?
- Are there limits on the number of times you can receive a service such as lifetime maximums or daily or annual benefit caps?
- Are there limits on the number of visits for certain types of care?
- What does the plan pay for? What does the plan exclude?
- Does the plan cover prescriptions? Are your prescriptions on the list of covered drugs? How about alternative or chiropractic care?
- If you travel, does this plan cover care outside your local area?
- If age 19 or older and applying for individual health insurance (not through an employer), do you have a medical condition that allows you to apply directly to the state program (Oregon Medical Insurance Pool) for people with pre-existing medical conditions? Call 1-800-848-7280 for information.
- Is your doctor in the plan's network, so you pay the least possible amount? If you don't have a doctor, are the doctors in your area who are taking new patients approved under the plan? How big is the plan's network?
- Can you choose your own doctor? Do you need referrals for specialists?
- Does the plan have doctors, pharmacies, and hospitals near your home or work?
How long does it take to reach a real person when you call the company? Does the company get a lot of consumer complaints? The Insurance Division consumer advocates can tell you how a company ranks in complaints. You can reach an advocate at: 503-947-7984 or toll-free at 1-888-877-4894.