Health insurance coverage is something you typically don't give much thought - that is, until you or someone you love needs it. This very thing happened in my family. My husband, son and I carried group health insurance through my husbands' employer. Shortly after we married, I persuaded my husband to switch from the Blue Cross plan (80/20) to the HMO offered by his employer. Premiums for the HMO were somewhat lower and there was better coverage for doctor visits and pharmacy.
Within 2 years of switching health plans, my husband was diagnosed with lymphoma, a slow-growing cancer. The prognosis was good, but treatments, medications, and hospital stays were exorbitant. Medical expenses would have been overwhelming had we not switched to the HMO plan. Our HMO health insurance plan covered almost all expenses we incurred with his illness. We basically only paid our co-pays, and, of course, our premiums. In fact, our health plan still pays for his treatments.
Should everyone change to an HMO health insurance plan? Not necessarily. What is important is to know basic facts about our health plan. Important questions to answer include:
What does the health plan cover? Does the coverage meet your needs? Some plans do not include wellness care and preventive care, while others do. If you require many prescription drugs, are these included in your plan?
What does the health plan NOT cover? Health insurance plans usually do not include cosmetic surgery (unless the surgery is reconstructive, repairing damage from burns, an accident, etc.). Major medical insurance plans will only cover hospitalization and other "major medical" expenses.
Who does the plan cover? Family coverage includes immediate family in most cases, spouse and minor children. Are children covered while in college, for example? Are stepchildren or children in custody of the other parent covered? Some health plans cover any child in the family, some cover stepchildren (usually only if they live with you, however). Some plans only cover children who live under your roof. What about foster children, or other children under your care (grandchildren living with you, etc.)
How much are co-pays and deductibles? Most managed care plans require co-pays whenever you receive health services, but may require no deductible. A fee-for-service plan typically includes an annual deductible as well as co-pays for services received.
What health care providers (doctors, pharmacies, durable medical equipment) are covered under your health plan. Most managed care plans (HMOs, PPOs) utilize a "network" of contracted health providers and may not cover providers out of their network. If choice of health care provider is important to you, you should ensure that your providers are in the plan network, or choose a fee-for-service (FFS) plan that covers any provider.