WHAT SHOULD I LOOK FOR WHEN I BUY HEALTH INSURANCE?

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1 WHAT SHOULD I LOOK FOR WHEN I BUY HEALTH INSURANCE? The Maine Bureau f Insurance 34 State Huse Statin Augusta, Maine r (in Maine) Paul R. LePage Gvernr Eric Cippa Superintendent Few decisins are as imprtant as chsing health insurance; hwever, chsing the right insurance can be difficult. There are many things t cnsider befre yu make a final decisin. Befre buying a plicy, it is very imprtant t learn what plans ffer and which plan wuld meet yur needs. This brchure is intended t help peple t shp fr health insurance plicies fr themselves r their families, peple receiving Medicare wh are lking fr supplemental insurance, and peple wh are self-emplyed and eligible fr small grup plans. This infrmatin is a cmpanin piece t ther brchures available n ur website under Cnsumer Infrmatin/Publicatins. 1. Hw can I tell if a cmpany will prvide me with the insurance cverage I need? Make sure the cmpany is licensed in the State f Maine by lking n ur website under Licensee Search. Be careful when lking up a carrier's name t ensure that yu identify it exactly. Sme illegitimate plans use names that are very similar t licensed carriers. T becme licensed, the cmpany has t prvide the Bureau with dcumentatin that shws that they are financially stable. Anther gd resurce is a rating cmpany. Yu can use r t

2 find cmpany financial ratings. If yu dn t have Internet access, call us at (in Maine) and ask t speak t the persn wh can give yu an A.M. Best rating and license infrmatin. Other infrmatin yu may find helpful can be fund n the Bureau f Insurance website (www.maine.gv/pfr/insurance). Chse the Cnsumer Infrmatin link, chse the Publicatins heading and then select Health in the heading under Publicatins.. Yu may find the brchures listed belw f particular interest. Maine Cnsumer Guide t Health Insurers Small Emplyers Health Insurance, A Cnsumer Guide t Health, Disability and Lng-Term Care Cmplaint Cmparisn Individual Health Insurance, Guide t Medicare Supplement Cmparisn Chart 2. What abut discunt cards? Discunt cards are nt insurance. They prvide discunts fr health care services r prescriptin drugs. Yu have t pay all csts beynd the discunt. Sme discunt cards carry a mnthly r yearly fee. 3. What shuld I cnsider when I chse a health plicy? What d I need? First, determine yur wn health needs. The questins t cnsider include: D yu r yur family members have special health needs? D yu r yur family members need t see specialists regularly? D yu r yur family members have a cnditin that wuld be made mre difficult if yu culdn t see the persn whm yu cnsider t be yur primary physician r specialist? D yu r yur family members have an nging need fr prescriptin drugs? Hw d benefits cmpare? Once yu knw yur health needs, yu can cmpare the benefits ffered by each plan. The Cnsumer Guide t Individual Health Insurance The Cnsumer's Guide t Small Emplyers Health Insurance The Medicare Supplement Cmparisn Chart describe the benefits available.

3 Each plan may ffer sme benefits that meet yur needs, but chances are n plan will meet them all. Yu have t balance what yu need with what yu can affrd. HMO, PPO r Indemnity? Peple enrlled in a Health Maintenance Organizatin (HMO) generally must chse a primary care physician frm a list f participating dctrs. Fr any nn-emergency hspital r specialty care, enrllees must usually get a referral. A "pure" HMO plan des nt prvide benefits if yu g t a prvider wh is nt in the netwrk. A pint-f-service (POS) plan will pay a reduced level f benefits fr services prvided by nnnetwrk prviders. The plan may restrict hw yu may access the services, hw ften yu can use the services, and/r hw much the plan will pay annually fr the services. In a Preferred Prvider Organizatin (PPO), the health insurer cntracts with a netwrk f medical prviders wh agree t accept lwer fees and/r t cntrl medical csts. Peple enrlled receive a higher level f benefits if they g t a participating prvider than if they g t a nnparticipating prvider. In an indemnity plan, the health insurer des nt restrict yur chice f prvider. Benefits are usually limited t the "usual and custmary" fee fr the service. If yur prvider's fee is higher, the prvider will bill yu fr the difference. Benefits are als usually subject t an annual deductible and cinsurance. Cinsurance is a percentage f the fee (typically 20%) that yu must pay. Can I still see my current dctr? Find ut if the dctrs and ther health care prfessinals yu and yur family members use participate with the health plan. Determine if yur prviders are in the health plan s netwrk by checking the plan's prvider directries and by calling the prviders' ffices. If the dctr/prvider is nt part f the plan s netwrk, check the difference between cverage fr participating and nn-participating prviders. This will help yu calculate what yu wuld have t pay ut-f-pcket if yu really wanted t cntinue using that prvider. Ask yur prviders if they have had prblems with the insurance cmpany nt paying them n time r refusing t pay at all. Hw's the referral system? Des the cmpany cmplete referrals t anther dctr/prvider quickly and d they give yu ntice f the apprved referral? Ask yur dctr hw quickly the cmpany decides n referrals.

4 Hw s the custmer service? Service is als imprtant t cnsider. A cmpany that gives superir service may be wrth sme additinal cst if yu can affrd it. Sme measures f the quality f a health insurance cmpany s custmer service are fund n ur website in Maine Cnsumers Guide t Health Insurers. What s the bttm line? See the Individual Health Insurance, Guide t; Small Emplyers Health Insurance, A Cnsumer Guide t r Medicare Supplement Cmparisn Chart publicatins fr prices and plans listed by cmpany. Cmpare benefits and premiums carefully. Cnsider what deductible amunts yu can affrd. (Mst HMOs d nt use deductibles; hwever, they may require c-payments fr specific services.) See what parts f yur csts are paid by the plan, and whether this varies by the type f service, dctr, r health facility used. Cnsider what yur cpayments fr dctr and hspital will be, and whether yu can affrd the premiums f smaller cpayments vs. larger cpayments. Check whether there is a limit n hw much the plan will pay fr yur care in a year r ver a lifetime (keeping in mind that a single hspital stay culd csts hundreds f thusands f dllars). Can yu affrd it? If nt, yu r yur family members might be eligible fr MaineCare (frmerly called Medicaid). T find ut, call the Maine Department f Human Services at Hw lng d I have t keep this health insurance plicy? Generally, health care plicies g frm mnth t mnth, unless yu have signed a lnger agreement. Cverage may be cancelled if yu skip a payment. HELPFUL TIPS Dn't write a check, give ut yur bank accunt number r give any persn mney until yu are cmpletely sure that yu understand exactly what cverage yu are buying. Even if the persn appears trustwrthy, if yu feel at all cnfused - wait. Give yurself as much time as yu need t think abut it. Ask fr the business card f the individual selling yu the plicy. Als ask fr all dcuments related t the plicy and its benefits. Make sure yu get a receipt when yu d buy the plicy. Read yur plicy and knw where it is. If yu allw the insurance cmpany t deduct payments directly frm yur bank accunt and yu decide t end yur insurance, it culd take several mnths t stp the deductins and lnger still t get back the mney they cntinue t cllect.

5 Cmparisn shp. Request and read cpies f the insurers brchures describing benefits and hw t use them. Yu will find the cmpany telephne numbers listed in the Individual Health Insurance, Guide t Small Emplyers Health Insurance, A Cnsumer Guide t and Medicare Supplement Cmparisn Chart publicatins. Take the necessary time t learn all yu can abut the insurance yu want t buy. sk the pinin f peple wh yu trust and enlist their help in yur search. Is yur dctr familiar with this cmpany? Get the infrmatin yu need t ensure yu are cmfrtable with yur decisin. Dn't be afraid t ask questins. Never buy an insurance plicy yu d nt understand. When yur new insurance plicy arrives, lk it ver carefully. Make sure yu received the plicy that yu thught yu purchased. Yu have a 10-day "free lk" perid when yu may cancel the new plicy if it des nt meet yur expectatins. Keep gd files. Keep yur insurance plicy and all yur insurance recrds in a safe place where yu can easily refer t them. Knw yur rights: 1. Yu have the right t understand anything the insurance cmpany sends yu. If yu d nt understand the infrmatin yu received, call the cmpany and ask fr an explanatin. Ask the cmpany t put it in writing. 2. Yu have the right t disagree with yur insurance cmpany. Yur plicy r benefit bklet shuld tell yu wh t call when yu are nt happy with the cmpany. Yu have the right t appeal any cmpany decisin. 3. Yu have the right t knw wh is making medical decisins abut yu at the insurance cmpany. Ask the cmpany t send yu a list f names, titles, and qualificatins f these peple. Medical peple shuld make medical decisins. 4. Yu have the right t knw the reasn fr a denial f requested medical services. If yur cmpany denies a requested service, they must explain their decisin in writing. If the cmpany denies a requested service saying it is nt medically necessary, they must explain why. 5. Yu have the right t seek emergency services withut prir authrizatin in a medical emergency, but be sure t cntact yur insurer as sn as pssible after yu have gne t the emergency rm. 6. Yu have the right t have help when yu wrk with yur insurance cmpany. A relative, friend, dctr, r nurse may be willing t help. Yu always have the right t call the Bureau f Insurance fr help. Knw yur respnsibilities:

6 Other questins? 1. Yu have the respnsibility t understand yur cverage and call yur insurer if yu have any questins. 2. Yu have the respnsibility t get a referral frm yur Primary Care Prvider if yur plan requires referrals. Cntact yur insurer befre yu receive the referred services t make sure that they have received and apprved the referral. On ur website, check ut Frequently Asked Questins, and always feel free t call the Bureau at

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