Health Insurance FAQ's

Choosing between health plans is not easy. Although there is no one "best" plan, there are some plans that will be better than others for you and your family's health needs. Although no plan will pay for all the costs associated with your medical care, some plans will cover more than others. With any health plan you will pay a basic premium, usually monthly, to buy the health insurance coverage. In addition, there are often other payments you must make. These payments will vary by plan but essentially are deductibles and copayments.

Indemnity (fee-for-service) or managed care. Indemnity and managed care plans differ in their basic approach. The major differences concern choice of providers, out-of-pocket costs for covered services, and how bills are paid. Usually, indemnity plans offer more choice of doctors (including specialists, such as cardiologists and surgeons), hospitals, and other health care providers than managed care plans. Indemnity plans pay their share of the costs of a service only after they receive a bill. Managed care plans have agreements with certain doctors, hospitals, and health care providers to give a range of services to plan members at reduced cost. In general, you will have less paperwork and lower out-of-pocket costs if you select a managed care-type plan and a broader choice of health care providers if you select an indemnity-type plan. Besides indemnity plans, there are three basic types of managed care plans: PPO's, HMO's, and POS plans.

A PPO is a Preferred Provider Organization. You would use the doctors and hospitals within the PPO network or go outside of the network for care. You do not need a referral to see a specialist. If you join a PPO, you should find you have more flexibility than with an HMO, but your total out of pocket costs are likely to be somewhat higher.

An HMO is a Health Maintenance Organization. As a member of an HMO, you select a primary care physician from a list of doctors in that HMO's network. Your primary care physician will be the first medical provider you call or see for a medical condition. He or she will make any needed referrals to a medical specialist. Typically, these specialists will be part of the HMO network. If you join an HMO, you should find that you have few out-of-pocket expenses for medical care -- as long as you use doctors or hospitals that are part of the HMO.

An MSA is a Medical Savings Account. It is a tax-advantaged personal savings account used in conjunction with a high deductible health policy. Individuals can contribute money to this account on a pre-tax basis to set aside money for qualified medical care and expenses, including annual deductibles and copayments.

POS is a Point-of-Service Plan. This type of managed care plan combines features of health maintenance organizations (HMO's) and preferred provider organizations (PPO's). You can decide whether to go to a network provider and pay a flat dollar or to an out-of-network provider and pay a deductible and/or a coinsurance charge.

An indemnity plan is commonly known as a fee for service or traditional plan. If you select an Indemnity plan you have the freedom to visit any medical provider. You do not need referrals or authorizations; however, some plans may require you to pre-certify for certain procedures. Most indemnity plans require you to pay a deductible. After you have paid your deductible, indemnity policies typically pay a percentage of "usual and customary" charges for covered services; often the insurance company pays 80% and you pay 20%. Most plans have an annual out of pocket maximum and once you've reached this they will pay 100% of all "usual and customary" charges for covered services. Many health insurance companies have moved away from indemnity plans and are instead offering managed care plans such as HMO's and PPO's You may have few or no indemnity plan choices in your area.

A provider is a hospital, health care facility, physician or other medical professional that provides health care services.

A physician or other medical professional who serves as a group member's first contact with a plan's health care system. Also known as a primary care provider, personal care physician, or personal care provider

An office visit copayment is a fixed dollar amount or a percentage that you pay for each doctor visit. For example, with some plans you may pay a fixed amount such as $5 or $10 per visit. Other plans will charge you a percentage of the total fee for the visit. So if your copayment is 10% and the doctor visit was $200, you would pay 10% which, in this case, would be $20.

A deductible is the amount of annual medical expenses that a health plan member must pay before the plan will begin to cover expenses. For example, if your plan has a $500 deductible, you will pay the first $500 of your medical expenses before your health plan begins paying the expenses. Only expenses for covered services apply towards the deductible. For example, if you paid $100 for a visit to a chiropractor but the plan does not consider chiropractic care a covered expense, then the $100 will not apply toward your annual deductible.

An in-network medical provider is within the approved network of providers for a particular health insurance plan. Out-of-network providers are not on the list. If you visit a doctor within the network, the amount you will be responsible for paying will be less than if you go to an out-of-network doctor. In many cases, the insurance company will not pay anything for services your receive from outside their network; however, there are exception to this.

As a general rule, HMO's tend to have smaller provider networks than PPO's In HMO and PPO plans, referrals to specialists will be to doctors within the network. Indemnity plans typically do not have networks; you go to whatever doctor you want.

The payment must be made out in the name of the insurance company by check or credit card - neither of which will be processed until you have been approved. If you are not approved for coverage by the insurance company, your money will be refunded. Any financial information submitted over the web is kept private and secure. Once accepted as a plan member, all bills will be sent from the health insurance company and you will pay them via the choices offered by that company.

No. Insurance companies charge the same premium whether the plan is purchased directly from the company, through a insurance broker, or online.

Because we work directly with 25 of the industry's most prominent insurance companies, we can tailor a policy that fits all of your needs and find you the lowest price available anywhere. Remember, the price we quote is the price you pay.

When your employer went out of business, the group health insurance pool to which you belonged also ended. You're not eligible for COBRA coverage because there is no longer a group under which you could continue your group health insurance benefits. Likewise, if you had already left your employer, enrolled in COBRA, and then your employer went bankrupt, your COBRA coverage would end. Check with your Lighthouse representative to find out if you are entitled to continued health care benefits under the New York State COBRA plan.

Keep in mind, too, that you must have been covered under an employer's health plan to be eligible for COBRA. If your employer doesn't offer health insurance, has less than 20 employees, or offers health insurance to only certain groups of employees (and you're not one of them), you won't qualify for COBRA benefits.

You will be responsible for paying the full monthly premiums that your employer previously paid, plus a slight administrative fee of up to 2 percent. For a single person, premiums could easily top $200 a month, and $600 or so for a family. While those payments might come as a shock to your wallet, the alternative is trying to find an individual health plan until - or if - you can get into another group plan. An individual plan (which, despite its name, can cover a family) is going to be more expensive than COBRA for the same benefits. And if you or your dependents have any sort of illness, it's highly likely the insurance company will not insure you.

If you do not currently have health insurance through your employer as part of a "group health insurance" plan, Lighthouse offers health plans to people who are self-employed to be a "group of one," and will offer you group coverage. Our plans also have "open enrollment" periods, which is an annual window for individuals to join.

As of this moment, if an employer is paying all or part of your insurance premiums, your employer can make participating in the company health plan as a condition of your employment. While this may not seem fair, in some states, insurance companies can require a "minimum" number of participants in order for the employer to be eligible for group coverage. You decision to decline insurance could impact the ability to have affordable health insurance for all employees within the company.

We can help you with additional supplemental insurance coverage that can help fill the gap in what is covered by your medicare coverage. Just give a Lighthouse Insurance agent a call at 1-888-399-0300 to learn more.

The health insurance industry uses an informal practice called the "birthday rule." Under the birthday rule, the health plan of the parent whose birthday comes first in the calendar year is designated as the primary plan.

Your kids might be eligible for health insurance through a joint federal-state program called the Children's Health Insurance Program (CHIP). CHIP is designed to provide coverage for children whose parents, for whatever reason, can't afford health insurance but make too much money to qualify for existing welfare programs.

Unfortunately, Medicare doesn't adequately cover the expenses of long term care. Instead, it's recommended that you get a combination of Medicare, Medigap, and long term care insurance to secure your financial future. You have to be careful when choosing a long term care policy in order to avoid the common pitfalls. Call a Lighthouse Insurance representative to answer any questions, (888) 399-0300.