logo

Saving & Improving lives since 1996

Healthcare Options in the USA

The Different Types of Health Insurance Plans In the USA

Health insurance is something you know you need, but most people are unclear as to what the options are, this page should help you make sense of what is best for you and your family.  Approximately 70% of people in the United States have health insurance through their employer or union. Others seek out an individual or family health plan through a healthcare exchange, an agent, or an insurance company.
Under the Affordable Care Act (ACA), commonly referred to as “Obamacare,” everyone is now required to have a major medical policy with specific minimum essential coverage; you may have to pay a tax penalty if you don’t have one. Those with pre-existing medical conditions are also guaranteed coverage.  Most plans will have an open enrollment period annually. During these times you can change coverage, providers or both. It is important to know YOUR dates and ensure you do not miss open enrollment options. 



Major medical insurance plans

Under the ACA, medical plans must offer minimum essential coverage, meaning that no one can be turned down for a plan during the Open Enrollment Period for  medical reasons, including pre-existing conditions. In addition, certain services and treatments must be offered in all health plans, regardless of where you  buy the plan or from what insurance company.
Rates for policies vary greatly and you may need to shop around to get the best rate for you and your family. A review of national surveys indicates 

• An Individual coverage premiums averaged at $280 per month, while family plan premiums averaged at $930 per month. (these are national averages)
• Individual plans average annual deductible was $4,120 and family plans average deductible was $7,760.
.
Major medical insurance plans come in several different formats, as described below:

Health Maintenance Organization (HMO) plans:
HMOs are one of the most popular types of health insurance you can purchase, and for those with HCM – may well be  a poor choice as it limits access to many high volume HCM Centers of Excellence. With this plan, an entire network of health care providers agrees to offer you  its services. You have to select a primary care provider (PCP) who coordinates all of your health services and care.
HMOs usually offer coverage for most types of preventive care, including specialist visits; but, specialist visits are only covered when your PCP makes a referral. Additionally, you will pay small copayment fees for every medical visit. HMOs are usually best suited for individuals and families that plan to see their PCP on a  regular basis for check-ups and not those with complex chronic illness. 

Preferred Provider Organization (PPO) plans:
Under a PPO plan, both you and your family can see any health care provider in their network, including specialists, without a referral. In most cases, you don’t have to choose a PCP and small copayment fees are charged for each visit. Individuals who visit a specialist regularly generally prefer this type of health insurance. This is the optimal plan design for those with chronic illness needed a specialist – example HCM Specialist.

Exclusive Provider Organization (EPO) plans:
With an EPO plan, you have access to all of the health care providers within the EPO network, including specialists. Additionally, EPOs will typically cost you less than HMOs and PPOs. The downside of this type of plan is that any provider outside of the EPO network isn’t covered by your insurance. EPO plans can be suited well to individuals who don’t anticipate needing a great deal of medical care and want to save money. There may well be a very limited number of “specialist” in an EPO – it is likely their definition of “specialist” is a cardiologist, not an HCM specialist.

Point of Service (POS) plans:
POS plans are a hybrid of HMOs and PPOs, so you will have to select a PCP for regular check-ups and referrals. But you can also use  out-of-network providers if you’re willing to pay more out of pocket; you’ll usually have a copayment as well. This type of plan is versatile, and can be right for people who are willing to pay a bit more for extra flexibility. This plan design is not well suited for those seeking many visits to an HCM Specialist, however for those who are stable (and with HCM we know that can change quickly) it may provide some cost savings, however it is a gamble.

High Deductible Health Plan (HDHP) plans:
This type of health insurance has a high deductible that you have to meet before your health insurance coverage takes effect.  In 2014, individuals paid a $1,250 deductible and families paid a $2,500 deductible. These plans can be right for people who want to save money with low monthly premiums  and don’t plan to use their medical coverage extensively.
HDHPs are often coupled with a Health Savings Account (HSA). If you already contribute money to an HSA, you can buy an HSA-compatible health plan.The plans that allow  you to continue contributing to your HSA are typically the ACA “bronze” and “silver” plans. Those plans cover only 60% and 70%, respectively, of the typical patient’s medical costs, so HSA funds are ideal for covering the out-of-pocket medical expenses. While it may not appear so on the surface, these plans may make sense for some  HCM families – a review of the past 3-4 years of health expenses and your current premium options may actually show a significant savings, however, you need to be able to pay the large deductible in one shot rather than a weekly/pay period deduction. It also requires a bit more paperwork from the participant.

To apply for a plan through the exchange, a part of the Affordable Care Act, Click here

Medicare:(to learn more click here)

Your Medicare coverage
Find out if your test, item, or service is covered. This page includes a link to a list of covered services for people with Medicare, a family member 
or caregiver. There's also a link to covered services for Medicare contractors, providers or other healthcare industry professionals (includes ability to search by CPT/HCPCS code).

Your Medicare coverage choices
There are 2 main ways to get your Medicare coverage — Original Medicare or a Medicare Advantage Plan (Part C). Use these steps to help you decide which way you want to get your coverage. Before you make a decision, you can get local, personalized Medicare counseling from the State Health Insurance Assistance Program (SHIP). Click here to find a local SHIP representative:


What Part A covers
Read about what Medicare Part A (hospital insurance) covers, including inpatient care at a hospital, skilled nursing facility (SNF), and hospice. 
Part A also covers services like lab tests, surgery, doctor visits, and home health care.

What Part B covers
Learn about what Medicare Part B (medical insurance) covers, including doctor and other health care providers' services, outpatient care, 
durable medical equipment, home health care, and some preventive services.

What drug plans cover
Learn what Medicare drug plans cover, including information about a drug formulary and tiers.

What Medicare health plans cover
Learn about Medicare health plans, which provide Part A and Part B benefits to people with Medicare. The plans include Medicare Advantage, 
Medicare Medical Savings Account (MSA), and Medicare Cost plans, and Demonstration/Pilot Programs, Programs of All-inclusive Care for the Elderly (PACE), and Medication Therapy Management (MTM) programs for complex health needs.

Preventive & screening services
Learn which preventive and screening services Medicare covers to keep you healthy and find problems early, when treatment is most effective.

What's not covered by Part A & Part B?
Learn about what items and services Medicare Part A and Part B doesn't cover. You'll have to pay for the items and services yourself unless you have other insurance or you're in a Medicare health plan that covers them.
If you have Medicare and other health insurance or coverage, each type of coverage is called a "payer." When there's more than one payer, 
"coordination of benefits" rules decide which one pays first. The "primary payer" pays what it owes on your bills first, and then sends the
rest to the "secondary payer" to pay. In some cases, there may also be a third payer.

What it means to pay primary/secondary
The insurance that pays first (primary payer) pays up to the limits of its coverage.
The one that pays second (secondary payer) only pays if there are costs the primary insurer didn't cover.
The secondary payer (which may be Medicare) may not pay all the uncovered costs.
If your employer insurance is the secondary payer, you may need to enroll in Medicare Part B before your insurance will pay.
Paying "first" means paying the whole bill up to the limits of the coverage. It doesn't always mean the primary payer pays first in time. 
If the insurance company doesn't pay the claim promptly (usually within 120 days), your doctor or other provider may bill Medicare. Medicare may make a conditional payment to pay the bill, and then later recover any payments the primary payer should've made.
If you have questions about who pays first, or if your insurance changes, call the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627. TTY users should call 1-855-797-2627.
 
Medicare benefits

8 things to know about Medigap policies
  • You must have Medicare Part A and Part B.
  • If you have a Medicare Advantage Plan, you can apply for a Medigap policy, but make sure you can leave the Medicare Advantage Plan before your Medigap policy begins. You pay the private insurance company a monthly premium for your Medigap policy in addition to the monthly Part B premium that you pay to Medicare. 
  • A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, you'll each have to buy separate policies. 
  • You can buy a Medigap policy from any insurance company that's licensed in your state to sell one Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company can't cancel your Medigap policy as long as you pay the premium. Some Medigap policies sold in the past cover prescription drugs, but Medigap policies sold after January 1, 2006 aren't allowed to include prescription drug coverage.
  • If you want prescription drug coverage, you can join a Medicare Prescription Drug Plan (Part D).
  • It's illegal for anyone to sell you a Medigap policy if you have a Medicare Medical Savings Account (MSA) Plan.
  • Medigap policies don't cover everything. Medigap policies generally don't cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing. Insurance plans that aren't Medigap
  • Some types of insurance aren't Medigap plans, they include: Medicare Advantage Plans (like an HMO, PPO, or Private Fee-for-Service Plan)

Medicare Prescription Drug Plans

Medicaid
Employer or union plans, including the Federal Employees Health Benefits Program (FEHBP)
TRICARE
Veterans' benefits
Long-term care insurance policies
Indian Health Service, Tribal, and Urban Indian Health plans
Dropping your entire Medigap policy (not just the drug coverage)
If you decide to drop your entire Medigap policy, you need to be careful about the timing. For example, you may want a completely different Medigap policy (not just your old Medigap policy without the prescription drug coverage), or you might decide to switch to a Medicare Advantage Plan that offers prescription drug coverage.
If you drop your entire Medigap policy and the drug coverage wasn't creditable prescription drug coverage or you go 63 days or more in a row before your new Medicare drug coverage begins, you have to pay a late enrollment penalty when you join a new Medicare drug plan.
 
MEDICAID (to learn more click here)

Basic Health Program
Section 1331 of the Affordable Care Act gives states the option of creating a Basic Health Program (BHP), a health benefits coverage program for 
low-income residents who would otherwise be eligible to purchase coverage through the Health Insurance Marketplace. The Basic Health Program gives states the ability to provide more affordable coverage for these low-income residents and improve continuity  of care for people whose income fluctuates above and below Medicaid and Children's Health Insurance Program (CHIP) levels.
Through the Basic Health Program, states can provide coverage to individuals who are citizens or lawfully present non-citizens, who do not qualify
for Medicaid, CHIP, or other minimum essential coverage and have income between 133 percent and 200 percent of the federal poverty level (FPL). People who are lawfully present non-citizens who have income that does not exceed 133 percent of FPL but who are unable to qualify for Medicaid due to such non-citizen status, are also eligible to enroll.
Consistent with the statute, benefits will include at least the ten essential health benefits specified in the Affordable Care Act. The monthly premium and cost sharing charged to eligible individuals will not exceed what an eligible individual would have paid if he or she were to receive coverage from a qualified health plan (QHP) through the Marketplace. A state that operates a Basic Health Program will receive federal funding equal to 95 percent of the amount of the premium tax credits and the cost sharing reductions that would have otherwise been provided to (or on behalf of) eligible individuals if these individuals enrolled  in QHPs through the Marketplace.
Minnesota is the first state to implement the Basic Health Program, with coverage beginning January 1, 2015

CHIP - Children's Health Insurance Program

Benefits
The Children's Health Insurance Program (CHIP) provides comprehensive benefits to children. Since states have flexibility to design their own 
program within Federal guidelines, benefits vary by state and by the type of CHIP program.

Medicaid Expansion Benefits
Medicaid Expansion CHIP programs provide the standard Medicaid benefit package, including Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, which includes all medically necessary services like mental health and dental services.
States that provide CHIP coverage to children through a Medicaid expansion program are required to provide the EPSDT benefit. Dental coverage in separate CHIP programs is required to include coverage for dental services "necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions." For more information see CHIP Dental Care Goals and related Federal Policy Guidance.
States with a separate CHIP program may choose from two options for providing dental coverage: a package of dental benefits that meets the CHIP requirements,or a benchmark dental benefit package. The benchmark dental package must be substantially equal to the (1) the most popular federal employee dental plan for dependents, (2) the most popular plan selected for dependants in the state’s employee dental plan, or (3) dental coverage offered through the most popular commercial insurer in the state. States are also required to post a listing of all participating Medicaid and CHIP dental providers and benefit packages on insurekidsnow.gov.
 

Citations: 

https://www.medicare.gov/
http://obamacarefacts.com/obamacare-health-insurance-exchange/
http://www.medicaid.gov/index.html