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The Silver Lake Editors - Hassle-Free Health Coverage: How to Buy the Right Medical Insurance Cheaply and Effectively (How to Insure Series)

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The Silver Lake Editors Hassle-Free Health Coverage: How to Buy the Right Medical Insurance Cheaply and Effectively (How to Insure Series)
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Both a primer and a buyers guide, it offers up-to-date information and practical advice.

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Hassle-Fre e Healt h Coverag e How to Bu y the Righ t Medical Insuranc e - photo 1
Hassle-Fre e Healt h Coverag e
How to Bu y the Righ t Medical Insuranc e Cheaply and Effectivel y

SILVER LAKE PUBLISHIN G LOS ANGELES, CA ABERDEEN, W A

Hassle-Free Health Coverag e

First edition, third printing 200 Copyright 1999-2005 b y Silver Lake Publishin g

Silver Lake Publishin g 111 East Wishkah Stree t Aberdeen, WA 9852

For a list of other publications or for more information from Silver Lake Publishing, please cal l 1.360.532.5758. Fax 1.360.532.5728. Or visi t our Web site at www.silverlakepub.com .

All rights reserved. No part of this book may b e reproduced, stored in a retrieval system or transcribed in any form or by any means (electronic , mechanical, photocopy, recording or otherwise ) without the prior written permission of Silve r Lake Publishing .

Library of Congress Catalogue Number: Pendin g

The Silver Lake Editor s Hassle-Free Health Coverag e How to Buy the Right Medical Insurance Cheapl y and Effectivel y Pages: 26

ISBN: 1-56343-160- Printed in the United States of America .

ACKNOWLEDGMENT S

Assembling a book that includes this much information on a subject thats changing every few months is tough. Explaining complex issues in simple terms takes a lot of work.

The Silver Lake Editors who contributed to this book include Megan Thorpe and Christina Schlank. Thanks also to Sander Alvarez and Sue Elliot-Sink, who helped with the early drafts and research.

Hassle-Free Health Coverage is the sixth book in Silver Lake Publishings series on personal insurance for consumers.

This book is designed to give consumers a basic knowledge of health insurance forms and terms. Nothing in this book should be considered legal advice. If you have a legal problem with an insur ance company, please seek professional advice spe cific to your location and circumstances.

The Silver Lake Editors welcome any feedback. Please call us at 1.360.532.5758 . Fax us at 1.360.532.5728. Or you can e-mail us at editors@silverlakepub.com .

CONTENT S

TABLE O F

Chapter 1

The Basic Mechanics of Health Insurance

Chapter 2

Key Health Insurance Terms and Definitions

Chapter 3

How Traditional Indemnity Insurance Works

Chapter 4

The Major Medical Approach to Health Care

Chapter 5 How Managed Care Works

Chapter 6

Why Most People Are Covered by Group Plans

Chapter 7 How Medicare and Medicaid Work
Chapter 8 The Ins and Outs of Workers Compensation
Chapter 9 Cancer, COBRA and Other Special Coverage
Chapter 10 Choosing the Right Plan
Chapter 11 What to Do if You Have Trouble Making a Claim
Chapter 12 Tips for Smart Shoppers
Chapter 13 Politics and the Future of Health Coverage

CHAPTE R

THE BASIC

MECHANICS OF

HEALTH INSURANCE

If youve ever been sick or injured, you know that its important to have the right kind of health insurance. It pays for the pain to be abated...and the damage to be repaired. But, if your employer offers you a choice of health plans, do you have enough knowledge to make the right choice? In addition to medical expense coverage, do you need any other kind of insurance? What will happen if you are too sick to work? Or, if you are over 65, will Medicare pay for all your health care expenses?

If youre confused about the types of health coverage available and what coverage is best for you, your family and even your business, youre not alone.

Todays consumers are asking these same questions; and the questions arent always easy to answer. Many of the insurance agents and brokers who used to explain the details to people are gone. Companies that sell medical insurance rely on a shrinking number of experts to explain coverages to people and most of these experts focus their pitch on the start of a new plan with a client. If questions come up laterwhich is usually the casepeople often get some brochures and a shrug of the shoulders.

MAKING SENSE OF INSURANCE

Health coverage refers to a collection of insurance policies and government programs which pay for a range of costsfrom doctors and hospitals to more specific needs, such as long-term care expenses or disability insurance (which replaces lost income if you cant work because of an illness or accident).

Health insurance doesnt just cover medical ex penses. It provides payment of benefits for the loss of income and/or the medical expenses aris ing from illness or injury. So, health insurance is sometimes called other things, like accident and sickness insurance or accident and health insur ance. The different kinds of health insurance cov erages vary according to the methods of under writing, the injury or illness covered, types of in surers, types of benefits and services provided, types of losses covered, and the amount of ben efits available.

When people refer to health insurance , they usually mean group insurance offered by employersinsurance that covers such things as medical bills, surgery, and hospital expenses. Insurance companies call this comprehensive or major medical coverage, because of the broad protection it offers.

When health insurance first appeared in the United Statesin the mid-1800sit was sold by casualty insurance companies on a stand-alone basis and as an add-on to life insurance policies. Early policies covered losses due to accidental injuries. Later ones provided benefits due to illness as well as accidents.

Today, health coverage includes insurance policies and government-provided benefits. Most consumers are familiar with some of these. The terms fee-for-service and managed care appear just about everywhere. The specific kinds of managed care plans health maintenance organizations (HMOs), preferred provider organizations (PPOs), and pointof-service (POS) plansare also fairly common. But what do these terms mean?

Both fee-for-service and managed care plans cover an array of medical, surgical, and hospital expenses. Most offer some coverage for prescription drugs; and some even include coverage for dentists and other providers. But because there are differences that will make one or another plan right for you, it is important to understand each kind of plan.

FEE-FOR-SERVICE PLANS

Fee-for-service coverage generally assumes that a medical provider (usually a doctor or hospital) will be paid a fee for services rendered. The term refers to the way doctors are paid...regardless of who pays. Paying cash that is, unreimbursed out-of-pocket expensesfor medical treatment is a fee-for-service arrangement. However, most people dont pay cash for their medical care. Traditional health insurance what insurance companies call indemnity coverage is a fee-for-service arrangement.

With fee-for-service insurance, you choose the doctor you want to see; and you can choose a different doctor for any reaons, any time you feel like it. After youve been treated, you or your doctor submits a claim to your insurance company for reimbursement. You will only receive reimbursement for the covered medical expenses that are listed in your plan.

Services that are covered under your policy ar e generally reimbursed for somebut not allof th e cost. Many policies pay 80 percent of the costs .

(For a sample list of covered expenses and/or examples of non-covered expenses, turn to page 41 of Chapter 3.)

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