This page can be a starting point in the search for third party coverage. There are also some tips on how to fight denial of access to third party coverage. You cab use the
terms below in an internet search engine to learn more. Please e-mail me (address provided below) if you find any particularly good information resource.
Health "insurance coverage" is a way that Americans have chosen to finance illness expenses. It is a way of mitigating financial risk. You or your employer (if
you have group insurance through work) pays premiums to the insurance company in good faith that the company will assume the financial responsibility for the bulk of your medical
expenses.
When determining what medical care can cost when you have coverage, there are two parts to be examined: your risks (copays, deductibles, out-of-pocket co-insurance maximums)
and the insurance company's risks (the portion of your health expenses that they pay after you have paid your copay, deductible, etc.) The insurance company
will try to limit their risks through use of negotiating "allowable" charges with the provider and have been known to try to shift this
risk back to you or the provider through exclusions and specific handling of certain conditions.
Decades ago, insurance coverage amounted to coverage just for catastrophic expenses, such as a car accident. The individual budgeted for a certain amount of reasonably
predictable health-related expense in the same way one might budget for auto repair. Benefits-minded folks pressed for more and more "first dollar benefits" coverage
of lesser expenses before meeting one's deductible (wellness visits, routine screenings, immunizations, etc.) The thought process being that the less a
family has to consider costs, the more likely they thoughtlessly buy health related items and services. Insurance lingo for this disconnect from financial risk is "moral
hazard". At issue and seriously blurred, therefore, is personal and family "financial management" versus "risk management" The result of the
blurring has been an administrative and paperwork nightmare and out-of-control charges & costs.
Here is a look at a few your options for insurance:
- Individual/Family, personal, private commercial "indemnity
insurance" that you buy yourself; this is a
very unfriendly category to be in...you are all alone among "the
sharks":
- Representation against the 900 pound giant:You can usually purchase this in two ways: through an agent or from the carrier directly. There is no difference in cost
to you. Agents often represent more than one carrier and therefore can help you find the carrier and plan that is the best fit for you and your family. The agent can be
expected to help you understand your coverage and sort through claims questions. Buying from the company directly is often less personal and can mean you'll have to carry
the fight yourself.
- what plan type?: Check the
Insurance Information Institute or the South Carolina Department of Insurance to see what each type of health insurance is and if a
regular (commercial indemnity) insurance plan, a preferred provider organization plan (PPO), or a health maintenance organization plan (HMO) seems best for you. Ask friends
about who insures them, what plan type they have and if are they satisfied. If you know anyone in the medical field who works with insurance, ask which carriers are prompt
and thorough with handling claims and which carriers make the claims process more difficult.
- Become familiar with the different plan types available to you. Each insurance carrier is going to offer different plan types with different coverage. This is where
having an agent can be an advantage to you. Two of the more familiar plan types are copay plans and high deductible plans. Some high deductible plans may qualify to allow you
to open a Health Savings Account (HSA).
- Health Savings Account (HSA): an HSA lets you to set aside money in a tax-advantaged savings in order to pay for qualified medical expenses; it may also be used for
expenses not covered by the insurance such as dental or vision care. HSA Bank is a good place to learn more about HSAs, but many local banks and federal credit unions now
offer HSAs as well. Please note that as of Dec. 31, 2003, laws converted all medical savings accounts (MSAs), which were then only available to self-employed individuals,
to HSAs. This gave all individuals the opportunity to pay for their medical expenses with tax-free savings.
- getting idea of cost: you
might try an on-line quote service to get some ideas
and to see information and definition files, etc.
- a cheaper group way for employees without health
insurance: Check with hobby or other association, employer's business association, club, fraternal, or other organization for group insurance.
Your employer (who may not be able to afford health insurance coverage benefits for you) may be willing to pay for your annual membership in an organization with a
member's group health insurance plan (I'd guess that practically anyone might join
the Federation of American Consumers and Travelers and obtain their group insurance ). Those aged 50 or older can join liberal AARP or its conservative competitor,
USA Next.
- a cheaper group way for the self-employed: National
Assoc. for the Self Employed
- another way: The Defined Contribution Alternative
is a new way for individuals to pay premiums and have control
over where they obtain services; check Destiny Health at CDHCA as
an example.
- SimpleCare: simplified
catastrophic insurance for those willing to pay cash for negotiated
30-50% provider discounts!
- Prepaid doctor: You maintain 3rd party insurance or Medicare
(high deductible insurance for catastrophic care seems smart) and prepay
for a doctor's care. It is said that the average USA primary care doctor
can handle alone about 2500-3000 patients for a year. As insurance
companies press fee payments lower and all other expenses increase
for the doctor, he/she must be ever more in a hurry to handle each
patient visit as briefly as possible. MDVIP is
a type of medical practice where checkups and doctor visits are handled
be a particular doctor who limits himself/herself to 600 patients,
each of whom prepays for a year of attention (including house calls)
for $1500 per year (less than a cigarette smoker spends per year on
the habit).
- state high risk pools: S. C. Health Insurance Pool
for individuals otherwise uninsurable due to pre-existing illnesses
800-868-2500, ext. 42757 (check with your state's Dept.
of Insurance).
- Individual insurance coverage through a "group": I'd
guess that practically anyone might join the Federation
of American Consumers and Travelers and obtain their group
insurance ; or check
with hobby or other association, employer's business association,
club, fraternal, or other organization for group health
insurance.
- Employer (company/independent contractor/self-employed) provided health
insurance deals (many Americans get coverage this way, and your
employer's "company benefits representative" is sort of an indirect "agent" to
help in fights with the insurance company):
- Employer-sponsored conventional insurance: group health insurance using regular indemnity, HMO or PPO. In many cases the employer and employee share the cost of the premium,
though the employer can choose to contribute only toward the coverage of the employee, which means that coverage of a spouse/family is entirely the responsibility of the employee. The
employer may offer payroll deduction, allowing the employee to pay for their insurance with pre-tax dollars. Many employers offer tiered plans (2 or more types) and the lowest-cost ones
may have a LOT of uncovered services (such as pathology or lab or radiology fees). You should read your outline of coverage carefully, noting limitations in coverage.
- Employer-sponsored HSA: These work in the same way as they do on an individual basis, above. A tax-favored savings account is linked with
high-deductible insurance, and qualified medical expenses may be paid from this account. Any unspent balance rolls into the next year, and employee owns
the account. HSAs are portable, meaning that even if the employee leaves the company, they own their HSA and can associate it with a new high-deductible,
qualified plan. Plan notes for our medical group's interest.
- Employer-sponsored, payroll deductible Flexible
Spending Accounts (FSA) ("cafeteria
plans"; IRS Sect. 125 plans): with a health-expense component, it allows you to put up to $5000 per year of your paycheck into an account for expenses within the deductible portion of your company's health insurance plan. The key difference between an FSA and an HSA is that you have to use the money you deposit into an FSA that year or you lose the money. Therefore it is important each year to deposit only as much money as you intend to use on medical expenses. Until mid-2003, you had to "front" out of pocket money to pay for the medical expense; then file claims for re-imbursement from the FSA. Now, it is possible to link your FSA with a debit card (an example is Metavante Healthcare Payment Solutions) so as to avoid the need to "front" the payment. The FSA-POP variant (premium only plan) of this plan allows employees to use the FSA to pay their health insurance premium (an example is Med-i-Bank)...a potential way to begin your company FSA!
- Employer-sponsored "consumer driven" health plan (defined
benefit account) (Personal Health Account): refers to defined contribution health plans under which the employee receives a fixed dollar contribution from an employer to choose among various plans. An employee who chooses a benefit-rich plan may have to contribute a significant amount of his own money in addition to the employer contribution, whereas an employee who chooses a less benefit-rich plan would pay less of his own money. Some say this is managed care with
a high deductible. Definity
Health is a company offering this type of plan (others
are Aetna, Humana, & Lumenos).
It is somewhat like the HSA...any unused contribution can roll into next year...but
without benefits being able to accumulate in the account above
$4000...the size of the deductible in the associated health insurance
policy (employer can put about $1000 per year single and $2000
per year family). But check changes in limits and other factors at Consumer Driven Health Care website.
- Employer-associated "captive insurance company":
the company does its own insuring...see the Riskman International's notes
- Employer-associated Health Re-imbursement Account/Arrangement (HRA): an arrangement where the employer reimburses an employee for qualified health expenses.
This does not need to be paired with catastrophic insurance coverage. This account is owned and funded by the employer. There is no cash value earned by the employee, and it is
not portable when the employee leaves the company. Funds from an HRA may be used to pay for the premiums of an individual health plan if the employer doesn't offer group
insurance. An employee's unused moneys from one year can be carried over
into the next year, & the Base
Group explains the HRA as they offer it.
- If you lose your job: if you had health coverage with
the company, you can continue coverage 18 months under COBRA
(though expensive, you should almost always chose this if you
can so that insurance does not lapse & cause you to have
a new 1 year waiting period for pregnancy or prior medical problems)
while you search for both a new job and health insurance coverage. This will depend on your group; ask your group benefits coordinator about the specifics of your groups COBRA continuation.
- CHAMPUS: US military.
- The Christian Care Ministry: a 501(c)3 non-insurance membership cost sharing cooperative since 1993, using Medi-Share.
- Free or low-cost mammograms and Pap smears: National
Breast and Cervical Cancer Early Detection Program and Best Chance Network (BCN) in
S. C.
- All About Retiree Benefits, Eldercare, various Assistance, including on-line application forms [HERE].
- Medicare, check here. (usually for those 65 or older).
- Medication assistance programs: senior citizen prescription drug programs such as South Carolina's SILVERxCARD program
(created in 1999), serving 50,000 South Carolinians as of Sept.
2004 (about 70% of funding from Medicaid). It is federally permitted
to continue in S. C. through the end of 2007, if DHEC agrees
and is available to those individuals making $1551/month or less
and couples making $2082/month or less. Will be replaced by Medicare
drug card in 2006..
- Other care for elderly: Palmetto
SeniorCare.
- For those with low financial means:
- Medicaid. In the first paragraph on this medicaid webpage, click on "select a state" to find details of Medicaid in your state.
- If you just don't have coverage, see the Cover the Uninsured promotion website & scroll to the "state guides" and click on that and select your state & read about the programs available.
- US Office of Family Assistance may have some ways to help.
- Disability...Social Security and/or
Medicare
- for those having trouble getting access to health care: The
Center for Patient Advocacy in McLean, VA (800-846-7444) [website disappeared
as of Sept. 2004].
- Genetic issues can be reviewed in certain areas of the Genetic
Alliance website.
[back
to the main insurance advisory index page]
(posted Aug. 2001; latest addition 21 August 2007)
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