FREQUENTLY ASKED HEALTH INSURANCE QUESTIONS
What is the major difference between Texas group and Texas individual insurance? There are many factors that influence the performance of these two types of plans including the evidence of insurability. To qualify for a Texas individual health insurance policy a person has to fill out an application that in turn is submitted to the insurance carrier for approval. The insurer then in turn may decline coverage or issue coverage depending on a persons habits, health, medical history and age. Also the insurer could issue the policy with imitations or riders that exclude coverage for certain preexisting conditions for the life of the policy. Texas group insurance on the other hand do not follow theses rules as in to were they have to accept you if you meet the qualifications and are not allowed to carve out current medical conditions and exclude them. The risk that is being taken is spread over the members of the group plan were the healthy people help spread the risk with the unhealthy people. The more healthy people in the group plan will bring the total group a better overall rate and when unhealthy people are added everyone’s premiums go up a bit. This is known as the “law of large numbers.”
What are other ways that individuals receive Texas health insurance protection? Besides enrolling in group and individual plans, people may also find coverage in federal and state government sponsored plans such as Medicare and Medicaid, as well as the Texas High Risk Health pool. Insurance in Texas may also be purchased privately on an individual or mass purchasing groups such as Texas credit unions and professional or trade associations such as HAMM a limited plan for musicians.
What are the advantages of Texas group insurance over Texas individual insurance? First if an employer wants to provide health insurance to their employees, Texas group insurance plans ensures no matter what the health conditions are of all employees, including the owner of the company, can be covered. Employees with pre existing health problems, who might not be unable to qualify for individual insurance, can be guaranteed covered automatically upon employment without evidence of insurability. There are some limits that can be imposed on new hires as in a waiting period from time of employment to after 3 months of employment but employees can receive coverage as soon as they are eligible from day one to not more than a three month waiting period. Group insurance can be more expensive than individual coverage for the fact that healthy people pay for the unhealthy people. Still for the employee it typically is cheaper for the fact that the employer at the very least has to pay for half of the employees premium but in most cases spouses and kids have to pay the full premium were as on a individual plan they are underwritten on their health and their health alone.
What types of group insurance do most Texas employers provide?
The four major types of insurance coverage provided by Texas employers to their employees are life insurance, accidental death and dismemberment, short-term disability and health insurance. Depending on the employer some also provide additional like prepaid legal and vision and dental care.
What is an HMO?
HMO stands for health maintenance organization which is a health plan design that provides comprehensive health care to the policy holder which has to see a primary care physician first to control medical cost’s instead of going directly to a specialist. Members pay a copay for most services instead of a reduced rate that is applied to a deductible like PPO plans.
What is a PPO?
PPO stands for preferred provider organization which is a health plan that contracts with a group of doctors, dentists, hospitals or other health care service providers to provide care at prearranged rates or discounts with all services are assigned a CPU code and a prearranged set price per code.
What is a risk?
The risk or claim is what an insurance company assumes when it agrees to issue a particular group or an individual. This is the chance of financial loss inherent in the group or individual. Insurance companies use it to determine whether they will issue an insurance policy on a particular group or individual.
What is a mandate benefit?
A mandate benefit is a specific coverage that an insurer is required to include in its contract under state law. Some of these mandates include coverage for substance-abuse treatment, coverage for newborn children, mental and nervous disorders and hospice care as well as others.
What kinds of hospital outpatient expenses are covered?
Include: emergency treatment, surgery and services rendered in the outpatient lab or x-ray department.
What types of services are generally covered by health insurance plan? $ Specified ambulance services.
$ Rental of durable mechanical equipment required for therapeutic use.
$ Artificial limbs and other prosthetic appliances, except replacement of such appliances.
$ Casts, splints, trusses, braces and crutches.
$ Rental of a wheelchair or hospital-type bed.
$ Professional services of doctors of medicine and osteopathy and other recognized medical practitioners.
$ Hospital charges for semiprivate room and board and other necessary services and supplies.
$ Surgical charges.
$ Services of registered nurses and, in some cases, licensed practical nurses.
$ Home health care.
$ Anesthetics and their administration.
$ X-rays and other diagnostic laboratory procedures.
$ X-ray or radium treatment.
$ Oxygen and other gases and their administration.
$ Blood transfusions, including the cost of bloom when charged.
$ Drugs and medicines requiring a prescription.
What is a deductible?
A deductible is a set dollar amount that an individual must satisfy before the insurance company begins to pay for expenses. Typically the higher the deductible, the lower the health insurance premium will be. Each person covered under a group or health insurance policy must meet a deductible before expenses will be reimbursed. Most family plans limit the amount of deductibles to one to three for everyone on the policy.
What is coinsurance?
Coinsurance is the provision found in health insurance policies. After the deductible is met then a percentage of covered expenses that the policyholder and the health insurance company will pay. Coinsurance levels range from 20 percent of the expenses the insured pays and the insurer pays 80 percent to 100 percent that the insurance company pays after the deductible is met. What is a covered expense and are there limits? A covered expense is an eligible expense under the health insurance plan. A covered expense is an expense incurred by a covered individual that will be paid in whole or in part under the health insurance policy.
Are all prescription drugs covered under Texas health insurance plans?
Prescription drugs that are prescribed for treatment of an illness or injury are covered and most of the time subject to applicable copays and in some case’s a prescription deductible has to be met separate from your medical deductible. Some insurance plans do not cover contraceptive prescription drugs or if you have a waiver for a specific condition. There are a number of variations, but the principal types of prescription medication plans are open panel, closed panel, mail order and prescription drug card plans. In most case’s copays kick in after the RX deductible has been met and can range from $10 for generic medications to $100 copay for non formulary prescriptions.