Health Insurance FAQ

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Health Insurance Questions


What’s the difference between individual, family and group plans?

An Individual plan is health insurance for one single individual up to age 65. A Family plan includes more than one person. This could be you and at least one other family member up to age 65. A group plan is health insurance offered by a business or organization to the employees. A group plan would generally consist of an owner plus at least one employee. If an employer does not offer group health insurance, then an individual or family plan is a great alternative.

How does a PPO work?

Preferred Provider Organization (also known as PPO) is a provider network consisting of preferred doctors, hospitals and other healthcare facilities. These healthcare providers and facilities are specifically contracted by the insurance company to provide medical services to those insured at a discounted rate. You are not required to choose a primary care physician when you apply for an individual or family PPO health insurance plan. You can go to any medical facility (including specialists) for medical treatment however, it is highly recommended that you visit only those facilities that are specifically contracted (In-Network) in order to avoid additional out of pocket expense with a non-contracted facility (Out-Of-Network). Check the provider directory online at the insurance company website to see if your doctor or facility is specifically contracted. It’s not a good idea any more to contact a medical office and ask them if they accept PPO plans. They will all tell you yes because they want your business. If you visit a facility that is not specifically contracted, you will pay extra out of pocket expenses. If you are going to call the doctors office and inquire, ask them if they are specifically contracted with your insurance companies plan. Take that information to the insurance company website for further verification. You can always call the insurance company directly to verify this information as well.

How does an HMO work?

An Indivdual HMO (Health Maintenance Organization) plan offers some of the richest benefits available. They can also be the most expensive compared to individual PPO plans. Don’t confuse this fact with group plans because group HMO’s tend to be less expensive than group PPO’s. With an HMO plan, you will have little or no out of pocket costs when you need medical attention. In most instances you will be required to choose a primary care physician (PCP). If and when you need medical attention, you can only go to that doctor. If you need a specialist, you need to get a referral to that specialist from your primary care physician. Just like an Individual PPO plan, it is very important that you visit only those facilities that are specifically contracted with your plan as In-Network providers. If you don’t, you will have either no coverage for that visit or extra out of pocket expenses will apply because you used an Out-Of-Network facility.

How does an HSA plan work?

An HSA is a health savings account. An individual or family plan that defines itself as an HSA compatible plan is a high deductible health plan (HDHP) that you can but are not required to use in conjuction with a health savings account. Not all high deductible plans are qualified to be HSA compatible plans. Only those defined as HSA compatible or are classified as an HSA, health plan are. You use your high deductible health plan for the big catastrophic event like hospitalization and you use your health savings account to pay for the smaller qualified medical expenses (as defined by the federal government) like prescriptions or lenses. The money that you contribute to your health savings account (subject to annual maximums as defined by the federal government) can roll from year to year. If you end up using that money for anything other than medically qualified expenses, a penalty will be assessed. Record keeping is very important. Health Savings Account transaction fees can vary. There may be some tax advantages to having an HSA account. Check with your tax advisor for more information.

How soon can my coverage start?

Depending upon the insurance company, you could request coverage as early as the next day (if short term or temporary insurance is requested) or any day in the future. With some insurance companies the earliest effective date that you can get is 15 days after your application is received by them. Some insurance companies will only issue the 1st or the 15th of the month effective dates. Check with the insurance company you are considering for their specific guidelines. Consider a short term or temporary insurance plan to use while your application is being reviewed to avoid a lapse in coverage.

What does an underwriting process mean?

After your individual or family plan application is received by the insurance company, an underwriting process begins. Your application will be viewed either electronically and\or viewed by an Underwriter who will assess your eligibility for coverage based on your application information and your medical history. The underwriter will make the final decision in terms of eligibility and your final premium. The underwriting process can take as little as a few days or up to 30 days or more all dependent upon how extensive your medical history is and if medical record information needs to be requested. If medical record information is requested upon your behalf, the application processing time slows down a bit while the underwriter waits for that medical record information to come through. During the underwriting process, you may even get a call from either the underwriter or an insurance company representative to conduct what they call a nurseline interview. They will ask you questions either related to information that you put on your application or information about something they may have found in your medical history that you need clarification on. It is very important that you communicate with this individual in order for the underwriting process to continue. If you do receive a call and you are not available, they generally leave a phone number and reference number for you to return the call. The nurseline interviews are becoming more and more common as insurance companies continue to improve their underwriting processes and strive for efficiency.

How do I meet my health insurance plan’s annual deductible?

Not all, but most insurance plans have a calendar year (JAN through DEC) annual deductible. This deductible is your share of costs that you will pay before all or some of your policy benefits are provided. A deductible typically is required for catastrophic type services such as hospitalization. It can also be required for some benefits such as blood and urine tests and even x-rays. Under the new health care reform law, preventive services (like an annual physical exam) is no charge, so therefore an annual deductible would not apply in this case. Some policies provide office visit coverage only after you meet a plan annual deductible. When you visit a provider (a doctor) they will process a claim on your behalf. Once the claim is processed, you may receive a billing statement from your provider billing you for services rendered. You will also receive an Explanation of Benefits (EOB) from your insurance company. The EOB, is a formal notice that states the provider’s name, date of service, actual billable charges for those services, how much was allowed, what your insurance company paid and what share of costs you will be responsible for if any. Any amount that you are billed for by your provider, should match exactly your payment responsibility noted on your EOB. If this amount does not match, contact your provider immediately. Generally amounts that you pay your provider (aside from any office visit copayments) get applied towards your annual deductible. The insurance company keeps track of this information for you and is visible on the EOB. Keep in mind that if you have a family policy, each family member may still be subject to a plan annual deductible. Sometimes, if 2 or more family members on the same plan satisfy a plan annual deductible, the deductible may be satisfied for the rest of the family. The bottom line is, every plan is different. Check with your particular policy to confirm which benefits will be subject to your policy deductible and what your specific deductible is.

Do you offer the best prices or can I get a better deal from the insurance company?

The premiums offered on our website are the same premiums that are offered by the insurance companies. The premiums are regulated by the Department of Insurance. There are no broker fees, application fees or cancellation fees by purchasing a plan using our site. We provide you with the necessary tools and information in order for you to make an informed decision.

Are you there for me even after I purchase a plan through you?

Absolutely! If you have a billing question, need to request replacement ID cards, need assistance with locating a doctor, want to change plans or have a question about your plan, just give us a call or send us an email. We are always available to assist you.

What payment options do I have?

When applying for a plan, most insurance companies require at least a first month payment with the application. The favored method of payment is MasterCard or Visa or debit from a bank account. Check with the insurance company you are considering for any recurring payment options or paper bill options. If the application gets approved, this first payment will be processed immediately. Never submit an application unless the funds will be available. There will be fees assessed with insufficient or returned payments.

What happens if I get declined because of a pre-existing condition?

Applicants under the age of 19 can no longer be declined for individual and family plans because of a pre-existing condition. However, they can be offered coverage at a higher rate because of a pre-existing condition or surcharged 20% for a period of no longer than 12 months because of no prior verifiable insurance coverage information provided. If you are age 19 to 65 and you get declined for coverage because of a pre-existing condition, don’t panic. Contact us and we can review your options. The eligibility underwriting guidelines can vary from company to company. Some are more lenient than others where certain specific conditions are concerned. Call or email us today about any pre-existing conditions that you may have. We can consult the guidelines and see what your chances are for becoming approved at a standard rate, a higher rate or if you could be a decline because of your pre-existing condition.

Can I negotiate what I pay for medical services?

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Can I Change Plans Later?
Downgrading is easy to do within the same kind of plan such as Share 500 to the Share 1500. Upgrading is possible if you are in good health as it is subject to underwriting. If you are currently an Anthem Individual member and are thinking of changing your current plan - go to ChangeMyCoverage.com to view your options. 

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