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WHAT SHOULD I LOOK FOR WHEN I BUY HEALTH INSURANCE?
The Maine Bureau of Insurance
34 State House Station
Augusta, Maine 04333
207-624-8475 or 1-800-300-5000 (in Maine)
Paul R. LePage
Few decisions are as important as choosing health insurance; however,
choosing the right insurance can be difficult. There are many things
to consider before you make a final decision. Before buying a policy,
it is very important to learn what plans offer and which plan would
meet your needs.
This brochure is intended to help people to shop for health insurance
policies for themselves or their families, people receiving Medicare
who are looking for supplemental insurance, and people who are self-employed
and eligible for small group plans. This information is a companion
piece to other brochures available on our website under Consumer Information/Publications.
- How can I tell if a company will provide me with the insurance
coverage I need?
Make sure the company is licensed in the State of Maine by looking
on our website under Licensee Search. Be careful when looking up a carrier's
name to ensure that you identify it exactly. Some illegitimate plans
use names that are very similar to licensed carriers. To become
licensed, the company has to provide the Bureau with documentation
that shows that they are financially stable.
Another good resource is a rating company. You can use www.ambest.com,
to find company financial ratings. If you don’t have Internet
access, call us at 1-800-300-5000 (in Maine) and ask to speak to
the person who can give you an A.M. Best rating and license information.
Other information you may find helpful can be found on the Bureau
of Insurance website (www.maine.gov/pfr/insurance).
Choose the Consumer Information link, choose the Publications heading
and then select Health in the heading under Publications.. You may
find the brochures listed below of particular interest.
- What about discount cards?
Discount cards are not insurance. They provide
discounts for health care services or prescription drugs. You have
to pay all costs beyond the discount. Some discount cards carry
a monthly or yearly fee.
- What should I consider when I choose a health policy?
What do I need?
First, determine your own health needs. The questions to consider
- Do you or your family members have special health needs?
- Do you or your family members need to see specialists regularly?
- Do you or your family members have a condition that would be
made more difficult if you couldn’t see the person whom
you consider to be your primary physician or specialist?
- Do you or your family members have an ongoing need for prescription
How do benefits compare? Once you
know your health needs, you can compare the benefits offered by
Each plan may offer some benefits that meet your needs, but chances
are no plan will meet them all. You have to balance what you need
with what you can afford.
HMO, PPO or Indemnity? People enrolled
in a Health Maintenance Organization (HMO) generally must
choose a primary care physician from a list of participating doctors.
For any non-emergency hospital or specialty care, enrollees must
usually get a referral. A "pure" HMO plan does not provide
benefits if you go to a provider who is not in the network. A point-of-service
(POS) plan will pay a reduced level of benefits for services
provided by non-network providers. The plan may restrict how you
may access the services, how often you can use the services, and/or
how much the plan will pay annually for the services.
In a Preferred Provider Organization (PPO), the health
insurer contracts with a network of medical providers who agree
to accept lower fees and/or to control medical costs. People enrolled
receive a higher level of benefits if they go to a participating
provider than if they go to a non-participating provider.
In an indemnity plan, the health insurer does not restrict
your choice of provider. Benefits are usually limited to the "usual
and customary" fee for the service. If your provider's fee
is higher, the provider will bill you for the difference. Benefits
are also usually subject to an annual deductible and coinsurance.
Coinsurance is a percentage of the fee (typically 20%) that you
Can I still see my current doctor? Find
out if the doctors and other health care professionals you and your
family members use participate with the health plan. Determine if
your providers are in the health plan’s network by checking
the plan's provider directories and by calling the providers' offices.
If the doctor/provider is not part of the plan’s network,
check the difference between coverage for participating and non-participating
providers. This will help you calculate what you would have to pay
out-of-pocket if you really wanted to continue using that provider.
Ask your providers if they have had problems with the insurance
company not paying them on time or refusing to pay at all.
How's the referral system? Does
the company complete referrals to another doctor/provider quickly
and do they give you notice of the approved referral? Ask
your doctor how quickly the company decides on referrals.
How’s the customer service? Service
is also important to consider. A company that gives superior service
may be worth some additional cost if you can afford it. Some measures
of the quality of a health insurance company’s customer service
are found on our website in Maine Consumers Guide to Health Insurers.
What’s the bottom line? See
the Individual Health Insurance, Guide to;
Small Employers Health Insurance,
A Consumer Guide to or Medicare Supplement
Comparison Chart publications for prices and plans listed
by company. Compare benefits and premiums carefully. Consider what
deductible amounts you can afford. (Most HMOs do not use deductibles;
however, they may require co-payments for specific services.) See
what part of your costs are paid by the plan, and whether this varies
by the type of service, doctor, or health facility used. Consider
what your copayments for doctor and hospital will be, and whether
you can afford the premiums of smaller copayments vs. larger copayments.
Check whether there is a limit on how much the plan will pay for
your care in a year or over a lifetime (keeping in mind that a single
hospital stay could costs hundreds of thousands of dollars).
Can you afford it? If not, you or your
family members might be eligible for MaineCare (formerly called
Medicaid). To find out, call the Maine Department of Human Services
- How long do I have to keep this health insurance policy?
Generally, health care policies go from month to month, unless
you have signed a longer agreement. Coverage may be cancelled if
you skip a payment.
On our website, check out Frequently Asked
Questions, and always feel free to call the Bureau at 1-800-300-5000.
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August 5, 2014