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10 Biggest Misconceptions About Health Insurance
Fact: By law the carrier must pay all claims that are filed and coded correctly or have been pre-approved. Insurance carriers have enough lawsuits, and they don’t want to be sued because they didn’t pay a legitimate claim. The issue typically is that a doctor did not code a claim properly, or that the subscriber was required to work with their doctor for pre-approval and this was not submitted or approved. Fact: Rates are increased based on age brackets and zip codes, and individual claims histories have no bearing on rate increases. Rate increases are based on loss runs from each plan. In order for health insurance to exist in the first place, we must have healthy people pay premiums to cover the cost for those that are sick. Someday we will all have claims, and those who are not using their policy should consider themselves lucky. “Our day will come.” Fact: The price and benefits are the same via agents. They have a wholesale relationship with the carriers. The service they offer is unbiased, as they do not work for the insurance companies and thus should not be “selling” one brand over the next. Fact: In California, there is non-maternity plans which cover all services except maternity. These plans have 30 to 40 percent lower premium costs. Fact: If you see a co-pay in your plan benefits (typically a dollar amount for an office visit) this equates to your deductible being waived. Fact: Very few things are ever “covered” 100 percent. One example that is covered in plans is a check-up. Most plans “cover” your well visit 100 percent . The word “coverage” is more appropriate, and means that you have benefits and that the insurance company will pay part of the bill. Fact: Yes you can go to any doctor. Every carrier, however, has a different network of providers. If you stay within this network (called the “in network” providers), your benefits are much better. If you go out of the network you still have coverage, but at a lower tier. Fact: By definition, all insurance plans have an out of pocket maximum for you, the subscriber. This is also referred to as “stop loss.” Once you hit this next threshold, your plans pay 100 percent. Fact: The co-pay of $100 is like your office co-pay of $30. This just processes you into the room. Once the x-ray, stitches or surgery occurs to fix what is wrong, your deductible will apply. It will cost you more than $100 to go to the ER. One alternative to help reduce out of pocket expenses is the urgent care. These services are typically billed as office co-pays, and this is a viable alternative for basic services. An HMO has a primary care physician that you need to see first before getting a referral, while a PPO plan allows you to self-refer. HMO benefits, however, are typically more comprehensive and offer better coverage. They lack the flexibility that a PPO offers. The PPO plans also typically have a deductible, while HMO plans do not have deductibles. Since finding health insurance in California is such a frustrating and time consuming process, it is natural for consumers to have so many questions and misconceptions on the subject. There is no way to avoid these misunderstandings, though, unless consumers are able to communicate with their insurance providers. So, always ask as many questions as you can about your health insurance. |
Health insurance is a tricky subject these days, and it seems like everyone is talking about it. Here are the top ten most commonly misunderstood or mistaken ideas that people have regarding health insurance in California:
I have a PPO plan and I can go to any doctor.