Question

You are a professor at the local University, through which you are insured for health care coverage through the University’s group plan with a Health Maintenance Organization. Your experience so far has been pretty good: you once fractured your clavicle and went to the urgent care clinic owned by the HMO. Your partner, who suffers from rheumatoid arthritis, is seen by her rheumatologist at the HMO’s group practice. Your son, Juanito, was in a car accident last year about 90 miles away from home and had to be taken to a local emergency room. The HMO paid the entire bill because it didn’t have a facility in that town to take care of him. Then, after Juanito had been home for three days, he developed a severe headache and became drowsy. He went to the same urgent care clinic you had gone to, received a CT scan, and was diagnosed with a subdural hematoma. He was immediately transported to the HMO’s regional neurosurgery center for surgery to evacuate the hematoma. He’s all better now but, almost as good, the HMO paid all the costs – all you had to pay was your monthly premium which the University deducts out of your paycheck. But now the University has decided it needs to control health care costs better, and is looking into a PPO plan, which has lower premiums and offers contracts with a “virtual network” of independent physicians and hospitals. The University has explained that this will mean more review for authorization (prior to being seen by a physician), and certification for any diagnostic tests (like x-rays and CT scans). Also, if you are seen by a physician not within the network (due to being out of town, or because of needing to see a specialist), some of the cost of those visits or services will be yours to pay. But, you will have a lower family premium taken out of your paycheck. You are confused by all the issues that affect insurance decisions these days and decide to map out the issues to discuss them with your partner. What are some of the issues that matter most to you?

Answer 1

Heath insurance

It refers to cover the unexpected medical expenses associated with an admission in to hospital due to various disease conditions ora motor vehicle accident.

Having insurance is always a good idea to protect your family from cost of medical expenses. However the term insurance is a highly confusing subject since, plans and premiums of insurance are plenty around and it creates a dilemma in choosing the best policy.

What are some of the issues that matter most to you?

1. Out of pocket expenses
2. Prescription drug coverage
3. Account eligibility of health saving
4. Network coverage of physicians
5. Available compliments and benefits