There are challenges for today’s Latino professional trying to navigate the insurance market when looking for health care.
So says fellow NSHP member and insurance broker, Leonor McCall-Rodriguez: "There are some things you might be missing or don’t know that can prevent you from being and staying healthy. Like getting the right coverage."
Here are some pointers she gives NSHP members:
-Insurance shopping is for healthy people.
This is a big one. If you are pregnant or have diabetes or have had that back pain for a couple of years, you’ve missed the timing for buying medical insurance in most states.
You didn’t buy the auto insurance after you rear-ended the car, did you?
Same thing here.
Barring a few states (where health care is very expensive), you have to buy it when you are healthy because individuals buying insurance go through a medical revision, a.k.a. underwriting, where the insurance company evaluates you as a risk and can decide whether or not to take you on as a member. Sick people do not get insurance easily today in any part of the U.S.
That’s because individual insurance can be very different from the insurance you get at work.
Under California law, for example, small business or small group insurance is guarantee issue. This means that even if you have some exotic disease or take expensive medication, you cannot be declined. The premium of the group may be higher, but when you apply as an employee, you get it. Not so as an individual subscriber.
- What exactly is the difference between a HMO and a PPO? Does the difference matter?
That depends. You have to choose based on what you prefer and think you need.
In an HMO, you have a family doctor who pretty much takes care of guiding your health care. The doctor is your “go-to person” for medical care and will refer you out to specialists, lab work, etc. You have to go through the doctor for everything, but there is a convenience of having some one do that for you.
In a PPO, you can see any doctor or specialist in the network by making an appointment yourself. It’s that easy. But you have to be willing to do some reading and legwork to figure out who you want to see for each occasion.
Consumers who value choice tend to prefer PPO. Families with little kids seem to like HMO’s better.
OK: Once I’ve figured that out, what should I look for in a plan?
Some easy things to keep an eye out for.
-Buy a plan that you are comfortable paying for. You don’t want to go through the whole process and then drop out because you’ve overextended yourself. Focus on having health insurance for the long haul.
-Find a plan that lets you see the doctor before paying the deductible.
This is a big one. Many plans available in today’s market do not let you have non-specialists and specialists visits until you pay thousands of dollars for the deductible. Read the little benefits line in the brochure and see if it says office visits with a co-pay amount and “deductible waived”.
-Consider getting a plan that has branded drugs as well as generic drugs, too.
More doctors prescribe generic drugs today, but if you should ever need a prescription that has no generic equivalent, you will be paying a lot out of pocket.
-Pay close attention to the Maternity benefit.
In most states today, there are many plans that do not include maternity benefits and if they do, there is a 12 month waiting period. If you are a young woman, make sure you have a maternity benefit.
Time your pregnancy. If you do get pregnant on a non-maternity plan, call your insurance company right away and ask them if you can move to a plan with a higher deductible that covers maternity. For some plans, they’ll allow that. You’ll pay more, but at least you’ll get some financial relief.
-The deductible, co-insurance and out-of-pocket maximum may not add up.
Read the information about deductibles and co-insurance very carefully. Every plan and brochure has a different way of stating their numbers.
The deductible is the money you pay up front for specific medical services as detailed in a plan. It’s always expressed in a fixed dollar amount.
Co-insurance is a shared cost and is a percentage. It is the part of a medical expense (usually major expense, like hospital and surgery) that you pay. The insurance company pays the remainder. The out -of- pocket maximum is the most you would pay in a year.
Beware. Sometimes the deductible is included in the out-of-pocket maximum. Other times, the brochure will say “co-insurance maximum and you have to add on the deductible yourself to get the out-of pocket maximum. Marketing is a great tool, but you need to make sure you are comparing apples to apples when choosing a plan.
So, that’s my two cents from the trenches as a Latina insurance broker.
Live smarter and buy your health care plan when you are healthy. Use it to stay healthy and use all your preventative benefits. And get the options and answers you need. Write your questions to email@example.com
Estar sanos es una parte de su plan hacia el éxito!