Evaluating Insurance Coverage

Issue:

Evaluating an insurance policy or insurance coverage

Background:

When choosing an insurance policy or coverage it is important to know what questions to ask and what information you should be aware of.

Information:

• Are you required to join an HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization) and how do you access medical specialist for yourself and your dependents?

• What is the cost of the policy and what does it cover?

• How much is the co-pay? (How much do you have to pay for prescriptions and medical procedures? How much does the insurance company cover? Is there a maximum amount you have to pay before the policy covers 100% of the charges?)

• What is the percentage of coverage for your patient and in-patient visits? (For example: 80% of the out patient charges are covered by insurance. The employee must pay the other 20%. This sounds like good coverage unless you are responsible for a percentage of lengthy out patient visits with may expensive procedures and/or tests.)

• Are there limitations or insurance exclusions? (For example: Some insurance companies consider bone marrow transplants experimental, for certain diseases, and therefore will not cover bone marrow transplants.)

• How much is deductible and over what period of time? (For example: You may have to have a certain amount in medical bills before the insurance either pays for everything and your major medical portion covers 100%, or there is another co-pay situation.)

• What is the policy appeal process? (For example: If there is a discrepancy in what is charged and what the insurance will pay? If so, how do you contest that?)

• Do you have the option of signing up for additional coverage? (For example: Can you sign up for additional dental coverage? Is there a supplemental cancer policy? Can you get catastrophic insurance that covers you after you use up all your sick leave and need to be on medical leave for days or months?

• If you have a spouse, you need to evaluate which insurance is better, which should be primary, whether it is worth carrying two policies.

• If you are or will be in college, your parent(s)/guardian(s) can continue to cover you on their policy until you are 25, as long as you are in college the entire time.

• If you and a spouse work for the same employer, how does that affect your insurance coverage?

• What happens if/when you leave an employer and need insurance until you secure another job? Eligibility is maintained under a federal law called COBRA. Although the federal government may be altering COBRA the second half of 1998 to extend coverage. (For example: Can your insurance coverage continue for a specified period of time? If you pay the premiums, how much will those premiums be, and how long can the insurance last?