• Different health insurance companies,
• Products available in your area
• Health Insurance definitions.

There are different types of health insurance to fit your needs.

The Web site also includes:

• Phone numbers and Web links to helpful agencies
• Answers to frequently asked questions regarding your health care

Major Medical Plans

A major medical plan covers illness and/or injuries. It also covers hospital care, drugs and doctors' visits. Major medical plans includes the following:

• Indemnity plans
• Preferred Provider Organization (PPO) plans
• Health Maintenance Organization (HMO) plans
• Point of Service (POS) plans

Indemnity Plans

An Indemnity plan is usually the most flexible in allowing you to choose where you want to get care. It may require one of the following costs:

• Deductible - The amount you pay before the insurance company begins paying benefits.
• Coinsurance - A percentage of the cost of care that you must pay.

Benefits include: No Network/Provider limitations..

Limitations of an Indemnity plan include:

• No coordination of services.
• Higher costs

Preferred Provider Organization (PPO) Plans

A PPO plan includes a group of "in-network" (Providers associated with the health plan) providers who provide services at discounted rates. It also offers "out-of-network" benefits. These benefits allow you to see other providers who are not with the health plan. You may have to pay a higher cost for these services.

Benefits include:

• Larger network of providers (both in and out of network)
• No referrals needed for specialists visits

Limitations of a PPO plan include:

• Higher monthly premiums
• Higher co-payments or coinsurance
• Less coordination of care among providers

Health Maintenance Organization (HMO) Plans

An HMO plan covers preventative services and routine health screenings. It allows you to get care when needed, without a lot of out-of-pocket costs. Many health problems can be taken care of before they turn into major problems.

Benefits of an HMO plan include:

• Emphasis on preventative care (e.g., health screenings and wellness programs)
• No claim forms for in-network care
• Affordable premiums
• Low out-of-pocket costs for physician visits and hospitalization
• Choice of primary care doctor from network of physicians
• More comprehensive care coverage (services and shared costs) than a PPO
• Improvement of services based upon continual feedback from members
• Constant update of health care quality standards for patient safety

Limitations of an HMO plan include:

• Maximum costs coverage restricted to members' use of specific physicians and hospitals contracted by health plan
• Primary care physician initiates referrals to specialists
• Non-emergency hospital care of members restricted to a network facility
• Members' responsibility for determining which hospitals are part of their HMO network

Point Of Service (POS) Plans

Primary care physician initiates referrals to specialists

Benefits of a POS plan include:

• Choice of physicians (in-network or out-of-network)
• Reimbursement for some portion of costs

Limitations of a POS plan include:

• Higher costs than an HMO (premiums, co-payments, and/or co-insurance)
• Reduction in plan's ability to insure quality and coordination of care

Limited Benefits Plans

Limited benefits plans cover certain health care settings, illnesses or diseases. Some options include:

• Basic Hospital Expenses - Covers a period of in-hospital care and outpatient services.
• Basic Medical-Surgical Expenses - Covers the costs of surgery; usually not less than 21 days of in-hospital care.
• Hospital Confinement Indemnity - Covers a part of the costs for each day in the hospital.
• Accidents Only - Covers the following:
  • only accidental death
  • dismemberment
  • disability
  • other hospital and medical care costs.
• Specified Disease - Covers diagnosis and treatment of certain diseases, like cancer.
• Other - Limited insurance coverage for only dental, vision, or certain accidents.

Discount Plans and Risk-Sharing Plans

Discount plans and risk-sharing plans are not insurance plans. Make sure you understand how the programs work and what benefits they offer you or your family.

Discount Plans - Provide access to services on a discounted basis. You pay the discounted fee to the provider.

Non-Licensed Risk-Sharing Plans - Groups or associations that will put your monthly payments in a savings account with other members. This money helps pay some of your health care costs as needed. Make sure that you check into the plan and weigh the benefits against the costs.

Fully Funded Plan

With a Fully Funded Plan the insurance company or HMO pays the claims. The member has to pay the co-payments or deductibles.

Self-Funded Plan

With the Self Funded Plan the employer or group sponsor pays for services. It is also called a Self-Insured Plan.

Medicare is a program administered by the Centers for Medicare and Medicaid services (CMS). This is a part of the federal government. People age 65 or older can get Medicare health care coverage.

• Part A coverage is automatically provided. It covers hospital services.
• Part B covers outpatient services; a person must enroll in Part B to receive coverage.
• Part C services and is also called Medicare Advantage plans. These products are sold by insurance companies or HMOs. These plans may include prescription drug coverage and hospitalization.
• Part D is the Prescription Drug Plan sold by insurance companies.

Medicaid is a government program. Each state has its own program that provides health and long-term care for low-income seniors and people with disabilities. It also covers pregnant women, children and their parents.

Each state has to:

• Create their own eligibility standards
• Determines the type, amount, duration, and services
• Decide how much to pay for services

Criteria for Medicaid Eligibility

To be covered by Medicaid, you have to meet certain criteria. You also have to be a member of a group that includes one of the following:

• Low-income children/families
• Pregnant women
• Elderly people with disabilities

Federal law requires that groups with certain low incomes must be covered. The coverage may be different in other states. The federal government and the state governments finance Medicaid.

In Georgia, the State Children's Health Insurance Program (SCHIP) is called PeachCare for Kids™. It provides health care for children through the age of 18.

The PeachCare for Kids™ program helps families who make too much money to qualify for Medicaid and cannot buy their own insurance. The children must live in a home where the income is at or below 23.5 percent of the federal poverty level.

By law the states have to provide certain protections. These protections might include:

• Appeal of coverage decisions within the insurance company
• Appeal of coverage decisions to an impartial external reviewer
• Prompt payment of claims
• Access to certain specialists and health care providers
• Coverage of specific treatments and services

Consolidated Omnibus Budget Reconciliation Act (COBRA) - If you leave buy insurance through your employer, when you leave your job, you can still keep your health insurance for a period of time.

Go to this Web site to find out more about COBRA. www.dol.gov/ebsa/

The Health Insurance Portability and Accountability Act of 1996 (HIPAA):

• Limits insurers' power to deny or delay claims
• Reduces your chances of losing your insurance
• Makes it easier to change health plans
• Won't let the company discriminate because of your health problems.

You can find out more about HIPAA by visiting this Web site. www.cms.hhs.gov/

Some Final Tips on Buying Health Insurance

• Make sure you feel confident about the insurance agent and company. It is a good idea to contact your state insurance department to determine whether the agent and the company are licensed in your state.
• Determine the kinds of policies that will meet you and your families needs. Choose the best one for you and your family. Don't hesitate to shop around and ask questions.
• Review the application carefully before you sign it. Make sure the word "insurance" is actually used and that there is no disclaimer, such as: "This product is not insurance, nor is it intended to replace insurance."

Certificate of Coverage (COC)

The COC outlines the terms of coverage and benefits available in a carrier's health plan.

Coinsurance (Co-insurance)

• A cost-sharing requirement under a health insurance policy that requires the insured to assume a portion or percentage of the costs of covered services.
• Health care cost which the covered person is responsible for paying, according to a fixed percentage or amount.
• A policy provision frequently found in major medical insurance policies under which the insured individual and the insurer share hospital and medical expenses according to a specified ratio.
• A type of cost sharing where the insured party and insurer share payment of the approved charge for covered services in a specified ratio after payment of the deductible.
  • Under Medicare Part B, the beneficiary pays coinsurance of 20 percent of allowed charges.
  • In a Medicare Prescription Drug Plan, the coinsurance will vary.
  • Many HMOs provide 100 percent insurance (no coinsurance) for preventive care or routine care provided "in network."

Consolidated Omnibus Budget Reconciliation Act (COBRA)

• Federal law that continues health care benefits for employees whose job has ended. Employers have to tell you about these benefits. If they do not inform you, they might have to pay a fine.
• COBRA lets the workers and their families keep their health insurance for a certain amount of time after leaving the job.
• COBRA is different for employees who leave their jobs voluntarily versus involuntarily (U.S. Department of Labor, 2002)

Co-Payment ( Co-payment, Co-pay)

The enrollee has to pay a certain amount for a specific service (such as $10 for an office visit or $5 for each prescription). Co-pay normally does not vary with the cost of the service and is usually a flat sum amount. With co-insurance you have to pay a percentage of the cost.

Deductible

Deductible is a fixed amount that you have to pay before your benefits begin.

Dental Health Maintenance Organization (DHMO)

A legal entity that accepts the responsibility of providing services at a fixed price. The enrollees in these plans must have dental care provided through designated doctors.

Lifetime Maximum

The total dollar amount, number of days, and number of visits that are allowed. There are different lifetime maximums for each benefit

Medicare Supplement/Medigap

Insurance sold to an individual or group that helps with some cost that the program does not cover. Medicare supplements cannot duplicate any benefits of Medicare. It may pay part or all of the deductibles or co-payments. It may also cover services and expenses not covered by Medicare.

Out-of-Pocket Maximum (Out-of-Pocket Limit)

A cap placed on out-of-pocket costs, after which benefits increase to provide full coverage for the rest of the year. It is a stated dollar amount set by the insurance company.