10-12-2022 PTL - Flipbook - Page 26
26 A Special Advertising Section of Baltimore Sun Media Group | Wednesday, October 12, 2022
FINANCIAL KNOW-HOW
Speaking health
insurance
Tips for working
with a broker
By Margit B. Weisgal, Contributing Writer
Y
ou are speaking with an insurance broker about health insurance options as she
rattles off a bunch of letters strung together. You hold up your hands and say,
“Whoa. Just a minute there. What do all of those mean?”
Here is a guide to what the most common initials mean and the types of plans to
which they refer. If you get your insurance
through your employer or by some other
means, you’ll come across plans such as
these. It’s in your best interest to understand
the differences.
For those getting health insurance
through the Affordable Care Act, Healthcare.
gov, the website for ACA health insurance
plans, is managed and paid for by the U.S.
Centers for Medicare & Medicaid Services
(CMS). “Depending on how many plans
are offered in your area,” it says, “you may
find plans of all or any of these types at
each metal level – Bronze, Silver, Gold, and
Platinum.”
These are examples of health insurance
plans in which you can enroll. These definitions are courtesy of CMS; however, they
are not always how a specific plan defines
them. See below for how some differ.
• Exclusive Provider Organization (EPO):
A managed care plan where services
are covered only if you use doctors,
specialists or hospitals in the plan’s
network (except in an emergency).
• Health Maintenance Organization
(HMO): A type of health insurance plan
that usually limits coverage to care
from doctors who work for or contract with the HMO. It generally won’t
cover out-of-network care except in
an emergency. An HMO may require
you to live or work in its service area to
be eligible for coverage. HMOs often
provide integrated care and focus on
prevention and wellness.
• Point of Service (POS): A type of plan
where you pay less if you use doctors,
hospitals, and other health care providers that belong to the plan’s network.
POS plans require you to get a referral
from your primary care doctor in order
to see a specialist.
• Preferred Provider Organization (PPO):
A type of health plan where you pay
less if you use providers in the plan’s
network. You can use doctors, hospitals and providers outside of the
network without a referral for an additional cost.
• Catastrophic health insurance plans
have low monthly premiums and very
high deductibles. They may be an
affordable way to protect yourself from
worst-case scenarios, like getting seriously sick or injured. But you pay most
routine medical expenses yourself.
Ronald Jacobson, Medi-Health, Inc.,
(ronjj@medi-health.net or 410-517-1017)
has been an independent insurance broker for more than 35 years, specializing in
health care policies. One of his areas of
expertise is medigap policies for those who
have Medicare. He is also one of the certified insurance brokers callers to Maryland
Health Connection can speak with when
they have questions about policies.
Jacobson clarified some of the differences in plans. “A PPO, preferred provider organization, may have a different network from
an HMO, a health maintenance organization.
A network is a listing of preferred providers
for all your health care needs. So, your doctor may be part of a PPO but not the HMO.
If you travel, you may want a policy with a
PPO because it is usually national in scope.
Most HMOs are more regional. With Points
of Service plans, most do not require referrals. Some HMOs also require a referral, but
not all. It is worth reading the SMC – the
Summary of Benefits and Coverage – that
every plan must provide.”
Summary of Benefits and Coverage
The CMS says, “Under the law, insurance companies and group health plans will
provide consumers with a concise document detailing, in plain language, simple
and consistent information about health
plan benefits and coverage. This summary
of benefits and coverage document will help
consumers better understand the coverage they have and, for the first time, allow
them to easily compare different coverage
options. It will summarize the key features
of the plan or coverage, such as the covered benefits, cost-sharing provisions, and
coverage limitations and exceptions. People
will receive the summary when shopping for
coverage, enrolling in coverage, at each new
plan year, and within seven business days
of requesting a copy from their health insurance issuer or group health plan.
Since the SBC is supposed to be written in “plain language,” request a copy to
review. Make sure you understand what the
plan provides and what you may be required
to do to have the plan pay for coverage. It
good to have it in writing.