Considerations When Purchasing Health Insurance
Khi mua bảo hiểm sức khỏe, có một số điều quan trọng cần xem xét để đảm bảo bạn chọn một kế hoạch phù hợp với nhu cầu của bạn và phù hợp với ngân sách của bạn. Dưới đây là một số yếu tố quan trọng cần xem xét:
Hãy nhớ rằng bảo hiểm sức khỏe là một quyết định tài chính quan trọng và việc chọn kế hoạch đúng có thể mang lại sự yên tâm và quyền truy cập đến các dịch vụ y tế cần thiết. Hãy dành thời gian để so sánh các lựa chọn và chọn kế hoạch phù hợp nhất với nhu cầu chăm sóc sức khỏe và tình hình tài chính của bạn.
Tôi có thể đến gặp bác sĩ và nhà cung cấp nào khác?
Mạng lưới nhà cung cấp của tôi lớn đến mức nào?
Tôi có thể gặp bất kỳ nhà cung cấp nào trong mạng lưới không?
Bác sĩ hiện tại của tôi có trong mạng lưới không?
Nếu tôi cần chọn một bác sĩ mới, có bác sĩ nào trong khu vực của tôi tiếp nhận bệnh nhân mới không?
Tôi có cần sự giới thiệu của bác sĩ để gặp bác sĩ chuyên khoa không?
Chương trình có bệnh viện và nhà thuốc gần tôi không?
Tôi có cần sự chấp thuận trước (ủy quyền trước) từ chương trình đối với một số dịch vụ nhất định không?
Nếu tôi đi du lịch thường xuyên, tôi có thể chăm sóc gì khi xa nhà?
Which doctors and other providers can I go to?
How large is my provider network?
Can I see any provider in the network?
Is my current doctor in the network?
If I need to choose a new doctor, are there doctors in my area accepting new patients?
Will I need a referral from my doctor to see a specialist?
Does the plan have hospitals and pharmacies near me?
Do I need pre-approval (pre-authorization) from the plan for certain services?
If I travel often, what care can I get away from home?
Considerations When Purchasing Health Insurance
When purchasing health insurance, there are several important considerations to keep in mind to ensure you choose a plan that meets your needs and fits your budget. Here are some key factors to consider:
Remember that health insurance is a significant financial decision, and choosing the right plan can provide you with peace of mind and access to essential healthcare services. Take your time to compare options and select the plan that best meets your healthcare needs and financial situation.
http://www.insurance.ca.gov/01-consumers/110-health/20-look/consider.cfm
Fortunately, the Affordable Care Act (ACA) makes it easier to get the right health coverage. All health insurance companies in California sell policies with a standard set of benefits (Essential Health Benefits) and fixed cost sharing (except for grand-fathered plans). This makes it easier for consumers to shop for health coverage. It’s like comparing apples-to-apples.
Some insurers also offer an alternate plan design. These may have more benefits and the cost sharing may vary.
Below are four things you should think about when choosing coverage – Costs, provider network, benefits, and quality.
Costs
When you buy individual/family coverage, your monthly premiums vary based on a few factors including your age, where you live, the number of persons covered, and how much of your coverage you will pay for out-of-pocket. It can be hard for consumers to pick which cost sharing is best for them. Visit our Health Insurance Costs page for more information that may help you with your choice.
Premiums are calculated differently if you are getting your coverage from your employer (group coverage). Sometimes employers will provide many plans for you to choose from with different levels of cost-sharing. Visit our Health Insurance Costs page for more information about premiums, cost sharing, and out-of-pocket expenses.
You also may have a choice between an PPO, EPO and HMO. Visit our health coverage comparison page for more information about the difference between the three.
Which doctors and other providers can I go to?
NOTE: If you want to keep or go to a specific provider and/or hospital, check with the insurer. You will need to find if they are a part of the network for the specific product you are buying. Just because a provider is a part of that insurer’s network for another plan, it does not mean that he or she will be a part of the plan that you are buying. Visit our Provider Network Adequacy page for more information.
What benefits does the plan offer?
Most insurance policies now offer a standard benefits, making it easier to compare of your choices. Visit our Health Insurance Benefits page for more details.
What quality of care will I get with this coverage? How does it compare to others?
Choosing a Plan
Health Plans Differ On Plan Type, Providers, Customer Service, Small Details
The health plans have enough differences within their administration to make them distinctive from one another. The first step is to determine which metal tier best meets your health care needs or that of your family. Remember, with Covered California, different family members can be enrolled in different metal tier plans AND with different carriers. You can have a Bronze with Kaiser while your spouse enrolls in a Gold plan with Oscar.
Even though the essential health benefits are the same, there are several elements that differentiate the health plans.
The real difference between the plans are the monthly rate, type of health plan (EPO, HMO, or PPO), provider network, customer service, and the details of the plan agreement. Everyone will prioritize these different elements according to what is most important to them. For some people, they are willing to pay more in order to get some of their preferred doctors in-network.
Monthly Premium Rate. The rates for the health plans are directly related to the contracts they have with medical providers (doctors, hospitals, labs, etc.) and the expected utilization of health care services in a specific region. Regardless of the monthly premium, you know that a Silver 70, from whatever health plan you select, will only have $8,750 maximum out-of-pocket for an individual.
Health Plan Type EPO, HMO, PPO. The health plan type is probably the largest distinction between the health plans. With the HMO design, you need a Primary Care Physician to refer you to most specialist and there is no out-of-network coverage. EPO plan types have no out-of-network coverage, but you can self-refer to most doctors in the network. PPO plan types usually offer the largest provider network, with no Primary Care Physician requirements, and potential coverage for out-of-network services once an out-of-network deductible is met.
Provider Network. The number and variety of providers in a network can be very important for some people. All health plans must meet minimum requirements for network hospitals, primary care doctors, and specialists. There will always be a specialist for a specific medical condition within the network of providers regardless of whether the plan is an EPO, HMO, or PPO. Some plans will have more providers than others, which can help reduce the wait time for an appointment. Of course, only certain health plans will have some of the more popular hospitals in-network.
Customer Service. Some health plans have better customer service than others. Customer service encompasses billing, paying claims, explaining health care charges, handling problems, changing the primary care physician designation, etc. Some health plans push members to use mobile phone applications to answer questions while other plans maintain properly staffed member service departments. Perhaps the least reliable indicator of customer service are the quality star ratings assigned to the health plan by Covered California. The ratings, based on a sample member population, seemed to be heavily influenced by individual biases. For each 2 star rated plan I can find people who had an excellent experience with the health plan. Similarly, there are people who have negative interactions with 4 and 5 star rated plans..
Plan Agreement. Also known as the Evidence of Coverage, the plan agreement or contract spells out how most of the routine health care services are covered. The agreement for EPO and HMO plans will state that no out-of-network services are covered. For PPO plans the agreement will note the out-of-network deductible. There can also be little interesting benefits and exclusions listed such as if you need health care services out of California and how those claims will be processed.
The Evidence of Coverage or Member Agreement can provide additional information on how the health operates, exclusions or added benefits
No Plan Exclude Any Essential Health Service
Even though all of the standard benefit metal tier health plan designs are mirrored between carriers, there can be profound differences between the health plans. What you don’t have to worry about is that a Gold 80 plan having a significantly different cost-sharing structure between health plans. You don’t have to worry that a Bronze plan won’t cover maternity compared to a Silver plan. All the covered benefits are the same. The big differences between the health plans lie in the monthly rate, the type, provider network, customer service, and details in the plan agreement.
