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Healthcare FAQs

Insurance

How much insurance coverage do I need?

Health insurance plans must have the same basic coverage: hospitalizations and emergency room visits, physician services including office visits and preventive care, diagnostic tests like x-rays, prescribed drugs, mental heath, rehabilitation, and nursing home care. By law, patients with pre-existent medical conditions cannot be denied coverage nor can they be billed at a higher insurance premium rate.

How much will the insurance cost and who will pay for it?

There are several forms of health care financing available. They can be sorted out by answering the following questions:

Are you 65 yrs. old or more? Medicare is available to consumers in this age group. Medicare coverage and payment to hospitals and physicians is the same across the nation. Medicare enrollment is simple and can be done online. (See Medicare website).

Do you have low income? Medicaid covers low income consumers in every state. It can provide major health coverage, especially to mothers with young children. However, eligibility rules and payment programs vary from state to state. Therefore you must check with your local state government for details. (See Medicaid website).

Are you a military veteran? The Veterans Administration provides benefits to anyone honorably discharged from military service. The amount of coverage depends on individual circumstances.

You can find information on VA.gov and get details at your local VA facility. Does your employer provide health insurance? If you work full-time at such a company, you may have some form of coverage already and should get details from your employer. You will likely pay some of the health care insurance premium and possibly other out-of pocket costs. Your employer can provide the details.

If you need more information see Healthcare.gov, and type Employee Insurance in the Search windowIf none of these options apply, you should shop for insurance through a federal or state-sponsored website. The websites will also help you determine if the federal government will pay some of your insurance costs. (See Healthcare.gov or healthinsurance.org to find the websites in your state.)

What is “Private Insurance” ?

Private insurance is the term for those plans funded by employers or purchased by individual consumers. Several websites provide excellent information about purchasing private insurance: Consumer Reports and CMS.

If you are purchasing insurance on your own, you may qualify for federal subsidies to help you pay for health care coverage. These subsidies apply to those with low incomes. That information can be found when you enroll in one of the federal or state health exchanges.

Note: the state and federally supported exchanges have “enrollment periods” to sign up for insurance. No enrollment can occur after the deadline, except in certain circumstances.

We have also listed websites where agents or other parties offer access to insurance. These services can be useful in purchasing health insurance when the exchange enrollment has expired.

These are the key points you should know about private insurance plans:

Monthly Premium: Health insurance premiums are billed monthly. Like all insurance, the more the coverage, the higher the premium. The health insurance industry has begun to use deductibles to reduce premium costs. This arrangement resembles automobile collision insurance. In exchange for a lower monthly premium, the consumer can choose a higher deductible, and take the risk of paying for some of the initial costs of care. The deductibles have a limit (also called a “cap”), after which the insurance pays for the costs of care. The most common plans on the exchanges have been labeled as follows:
Gold Plan – high monthly premium and low total family deductible
Silver Plan – moderate monthly premium and moderate total family deductible
Bronze Plan – low monthly premium and high total family deductible Details of these plans vary by state and the choice of a plan is a personal decision. Health consumers who rarely see the doctor may choose bronze plans to keep their premiums low. Others with more frequent health needs may choose a higher premium to keep the deductible costs low.

It is important to compare the coverage details provided by each plan. “Co-Insurance” is the term for how much you will have to pay for a service. For example, 20% coinsurance for a procedure or office visit means that the insurance company only pays 80% of the cost. You pay the rest. Make sure you understand how much you will pay out of pocket for office visits, hospitalizations, procedures, diagnostic tests and medications.

There are no “bargains” in health insurance coverage. If you choose a high deductible plan, your monthly premium will be less, because you are taking some financial risk for medical bills. You must pay those bills up to the limit of the deductible before the insurance company provides any payment. If you choose a lower deductible plan, your monthly premium will be higher, but you will pay a smaller portion of any medical bills.

Health Costs & Bills

How much will I have to pay for hospital care?

Hospitals have different prices for the same service. The “list” price is the charge to a “self-pay” (uninsured) patient. The “contracted” price is what an insurance company has negotiated for its clients. The “contracted” price is usually much lower than the “list price”.

For uninsured patients, some hospitals may to offer a discounted price. Hospital charges are often negotiable before or after services are rendered. Insured patients may still have to pay some of the hospital bill, depending on the type of insurance coverage they purchased.

What are out of pocket costs?

Out-of-pocket costs are additional payments made by the patient at the time a medical service or product is provided. In effect, these payments are additional charges over and above the insurance premiums. Typical out of pocket costs are:

Co-Insurance: some insurance plans cover only a certain percentage of the medical cost. For example, insurance would pay 80% of the cost of a procedure and the patient would pay 20%.

Co-pays: These costs usually apply whenever a patient has a physician office visit or service or purchases a prescription. The prices are set by the insurance company and are collected by the provider or the pharmacy.

Out-of-Network Fees: Some insurance companies negotiate discounted prices with networks of doctors and hospitals. The insurer can then offer consumers lower premiums if they join such a network and use its services. However, if the consumer goes “out of network” for a non-emergency service, the insurance company pays more and usually passes this extra cost on to the consumer.

What are deductibles?

Deductibles are out-of-pocket costs that work like auto collision policies. For the year, a consumer must pay his/her medical costs up to the limit described in the insurance policy (the “deductible”). Once that limit is reached, the insurance covers any additional costs.

For example, for a procedure costing $6000, a patient with a deductible of $5000 would be charged that amount if he/she had contributed nothing to the deductible that year. However, if that patient had already paid $5000 into the deductible, the procedure would cost him/her nothing.

The services charged to the deductible can vary by insurance plan and may include prescribed drugs.

By law, the maximum annual limits for deductibles are $6600 for an individual and $13,200 for a family. This means that no individual must pay more than $6600 for the year and for the family, the sum of all annual health payments cannot exceed $13,200.

How can I reduce prescription drug costs?

Generic drugs: About 80% of prescribed drugs are “generics” — drugs whose patents have expired. Generic drugs are usually (but not always) less expensive and are generally as effective as “brand name” drugs. In some cases, generic drugs are available “over-the-counter” (i.e. without prescription) and do not require a co-pay. Ask your doctor about this option.

Understand your medications: sometimes prescriptions can be reduced if you are doing well. Ask your doctor to review your prescriptions with you.

Manage your refills: For medications you take regularly, you may save money by changing the time for the next refill. For example, the costs may be less if your prescription is for a three-month supply of meds instead of one month supply that requires two refills. You may also save money by using an insurance mail order service. Check with your doctor and your insurance company for details.

If I have no drug insurance plan, what should I do?

Many commonly prescribed medications are inexpensive and you can shop online for price and special discounts.

Emergencies and Urgent Care

What is considered an emergency?

The American College of Emergency Physicians recommends that the following conditions be seen in an emergency facility: difficulty breathing, chest or abdominal pain or pressure, loss of consciousness, severe vomiting or diarrhea or bleeding. Other advice can be seen in the websites listed in this section.

When should I use urgent care?

Urgent care is designed to provide treatments that your doctor would usually provide in his/her office. Urgent care facilities are not designed to handle serious emergencies. They are best at managing temporary problems, like rashes, sore throats, colds, and minor orthopedic injuries. If your doctor’s office is closed, urgent care is a good option and is much less expensive than the emergency room. Insurance may cover some or all of the cost. However, if you go to an emergency room for a minor problem, your insurance company may make you pay some of the extra cost.

Who operates urgent care facilities?

Urgent care facilities can be owned and operated in a variety of ways: by physicians, hospitals, health systems, corporations, etc. Physicians and nurses staff many facilities. Others, like those in retail stores, are usually staffed by nurse practitioners.

Hospitals

How are hospitals organized?

Most hospitals are non-profit but some are owned by for-profit companies. Hospitals may be independent institutions or members of a large hospital organization or health system. These larger organizations may be local or national. This information can usually be found on a hospital’s website.

How can I be sure that a hospital is safe?

All hospitals must be accredited by the federal government to assure patient quality and safety. Besides accreditation, the government and other organizations have imposed other quality standards and ratings on hospitals. These results are on public websites listed in this section. These ratings can be difficult to understand and controversial because they use different methods. However, these flaws may be solved in the next few years.

How do I learn about a hospital’s programs?

The best source of information is on the hospital website.

What is a “Center of Excellence”?

The term can have many meanings. Hospitals may use this term to describe their major programs. The term may also represent a credential earned through an evaluation by an outside organization, using objective quality measurements. It is useful to look for this difference.

How do I find information about the doctors in a hospital?

Most hospitals have a “Find a Doctor” search function on their websites. The information lists the medical staff and their credentials, usually by name and/or specialty.

How should I choose a hospital?

Many patients prefer a hospital close to home. For any treatment or procedure you should ask your local hospital and/or physician about their experience with your condition: numbers of patients treated, complications, success rate, etc. Most studies have shown that experience and quality go hand in hand. For complex conditions, your doctor may advise going to a hospital specializing in that area.

Healthcare Websites and Symptom Checkers

What is a “Major Website”?

These websites offer information about a wide range of topics. The websites are reliable and usually edited and updated by physicians. These websites have been consistently helpful over many years.

What is the difference between commercial, non-profit and government websites?

The commercial sites have significant advertising. Theoretically, this could introduce bias, but these websites disclaim such influence. The non-profit websites have little or no commercial advertising but do promote their own services. The federal government websites offer excellent, unbiased information.

Some websites offer a “symptom checker” – what is that?

This service informs patients about medical conditions that could be associated with their symptoms. These tools are not very accurate in making the “right diagnosis”. Instead, they may help the patient decide if the symptoms warrant medical attention.

Physicians

How do I choose a physician?

For general medical needs, most consumers choose a local primary care physician (family physician or internist) affiliated with their community hospital. For a highly complex problem, you may need special expertise available at a regional or national facility. Your local physician can help guide this decision.

What information is available about a physician’s background?

All physicians have a similar portfolio of credentials:

Education: medical school, and residency training (required for all specialists including primary care physicians);
Board certification: successful completion of residency, and passing a certification exam.
Active state license to practice: reviewed and renewed every two years
Staff privileges: the hospital(s) where the physician practices; reviewed and renewed every two years
Insurances accepted: insurance companies review and renew physician credentials periodically

These details are available online from the websites listed in the Physicians topic section.

How reliable are websites and publications listing “the best doctors”?

The majority of this information is subjective, based on polls of doctors. Lately more objective information is emerging based on quality and patient outcomes. However, this information is still not perfect. A trusted health care professional is often the best advisor on finding the right doctor.

For more details, Consumer Reports has an excellent discussion on its website in the “Doctors” section, entitled “How to Choose a Doctor”.
Some websites, such as Yelp and Angie’s List, provide consumer ratings of physicians.

Making Appointments & Second Opinions

How do these websites work?

Making appointments: Some websites connect patients online with contracted physicians. The sites may also offer information about these physicians training, education, and patient ratings. These services are in the early development and may be limited by geographic range and a small number of enrolled physicians.

Second opinions and virtual visits: A number of websites offer second opinions and in some cases live, online visits. These services may be available only through contracts through employers or insurance companies.

Why do I need to know about procedures and tests?

Both diagnosis and treatment may depend on these studies, which are often confusing for patients. The listed websites provide details to help patients become better informed. This section has sections about radiology (imaging), cardiac (heart), digestive studies, surgical procedures, and lists of the common blood tests.

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