5 Questions to Ask Your Agent
Before You Buy California Health Insurance
Before you settle with your agent on a particular California health insurance plan to buy, there are five very important questions that you should ask her. These tough questions will help you get the information you need the most out of your agent regarding whether a particular proposed healthcare plan is really right for you.
1. How Much Are The Plan’s Fees, Including
Premiums, Deductibles, And Copayments?
Most of the California health insurance plans that you will look at are likely to have all three of these types of fees.
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Premiums are the fees that you are required to pay once a month and can run anywhere from forty to hundreds of dollars depending on the type of coverage.
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In contrast, deductibles are fees paid just once a year. These fee systems are not mutually exclusive and most insurers will employ both.
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In addition, many insurers also require you to pay a “copayment” or “coinsurance” payment every time the services are used. Depending on the type of plan, the “copayment” is often a percentage of the cost of medical services. For example: if your copayment is 20% and you undergo a medical procedure that costs $1000 then you will pay $200 and your insurer will pay $800. Some insurers however (HMO’s in particular) will charge a flat rate copayment for many services. In this case you might pay $10 for every doctor visit and $5 for prescriptions.
At this point you are probably feeling a little overwhelmed, and that’s understandable. These systems can be rather complicated. Just make sure that you go over each fee with your agent before purchasing insurance so that you can deliberate over these costs before you are obligated to pay for them.
A related question you might want to ask your agent is if the plan has a yearly “cap,” meaning that once your total fees including your deductable and copayments reach a certain point you will no longer be responsible for copayments. Basically a “cap” is the total amount you’re a required to pay in the worst case scenario within a given year. Therefore, the lower the cap, the better. If you’re deductible is $750 and your cap is $1,750 then once you have spent $1000 in copayments that year, your insurance company will be required to pay your medical bills in full for all covered procedures. Unfortunately, monthly premiums do not count toward your cap.
2. What Procedures, If Any, Are NOT
Covered Under This Plan?
Almost every healthcare plan in California has procedures that it is not willing to cover, or is only willing to cover in limited circumstances. The most common example is maternity. Many plans boasting enticingly low premiums will not cover any maternity expenses, or will only cover a small percent of costs. If you are a single man or a woman not planning to have children, this might not be a bad choice, but for a growing family or pregnant woman this is obviously something to avoid.
Maternity is not the only service which a lot of plans refuse to cover. Mental health services are also often times not covered by many healthcare plans. This is of course again likely to be reflected in lower prices. The plan may refuse to pay for visits to a psychiatrist or counselor. Different plans also have varying policies on preventative care such as routine breast exams or alternative treatments like massage therapy and acupuncture.
Once again, it is important to weigh all of these factors before jumping to conclusions about a plan. Make sure that your agent is amply aware of your unique needs, so that she can help you choose the best plan that suites you individually.
3. Will This Plan Allow You To Have The Doctor And Hospital Of Your Choice, Or Will You Be Arbitrarily Assigned A Doctor?
This is another incalculably important question, and weighs heavily upon the type of California health insurance plan you choose. A fee-for-service plan for example will generally allow you to choose any doctor you wish and switch doctors or hospitals at any time.
The drawback however to this type of plan is that the copayments are usually more expensive than other plans. HMO’s by contrast usually ask you to stay with a single doctor, but also charge far smaller and more predictable fees than fee-for-service plans.
Other plans such as POS’s and PPO’s offer intermediate plans in which you get a high level of coverage with a single doctor or “network” of doctors, but you receive limited coverage with other doctors or facilities. Make sure that your agent explains to you the details of your plan’s limitations as regards switching between doctors and health facilities.
4. Is There A Maximum Amount That The Plan Is Willing To Pay Over A Year, Or Other Stretch Of Time?
This is of course another very important question that should not be overlooked. If you remain healthy it is likely that a maximum benefit amount will never be a problem, but this can never be a certainty. The last thing that you want is to be in a position where your health plan refuses to continue to pay and you are not able to switch to another plan because of a pre-existing illness. Make sure that your agent explains to you any kind of stipulation of this sort before you sign on to a plan.
5. Is The Plan Flexible In Regards To Seeing A Specialist For Problems Beyond Your Doctor’s Field?
Many California health insurance plans will allow you to choose any specialist you desire, but some plans will only allow you to see a specialist if your doctor approves. Unfortunately, HMO’s are once again known for being rather inflexible on this point. This sadly once again reflects the pricing system. HMO’s being less expensive have to cut costs by limiting visits to specialists to instances that your doctor deems necessary.
Fee-for-service plans usually do not have such a stipulation, as having to pay for a percentage calculated copayment is often enough to discourage patients from visiting specialists if it is not specifically recommended by their doctor.
The bottom line is that you should make sure you know ALL the details about any California health insurance plan before you sign on. And since every person is unique, no one plan is right for everyone. You and your agent will work together to find a plan that suites both your lifestyle and your budget. Just make sure to ask all of the necessary questions.
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