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Health Insurance Plans: Which Plan is Right for You?

In Massachusetts you have access to many types of health insurance plans, a choice of cost-sharing features and many different ways to buy a health plan.

Table of Contents

Types Of Health Plans

Because there are many different types of health plans, you should be sure to look for the one that fits your needs. Comprehensive health insurance provides benefits for a broad range of health care services. These health plans offer a detailed list of health benefits, may limit your costs if you get services from one of the providers in the plan’s network, and typically require co-payments and deductibles. 

Here are some of the types of plans offered in Massachusetts

Health Maintenance Organization

HMO plans cover hospital, medical and preventive care. You are only covered if you get your care from HMO's network of providers (except in a case of emergency). With most HMO plans you pay a copayment for each covered service. For example, you pay $30 for an office visit and the HMO pays the rest of the cost.

Preferred Provider Plans (PPP)

Preferred provider plans usually cover hospital, medical and preventive care. These plans have a network of preferred providers that you can use, but they also cover services for out-of-network providers. PPP's will pay more of the cost if you use a provider that is in the network. Example: After copays and deductibles, the plan pays 100% of a service for a network provider but 80% for an out-of-network (OON) provider. Note that if you choose to go OON when you are in a PPP, your provider may balance bill you directly for the entire cost of the procedure. 

Major Medical Plans/ Indemnity Plans

Major medical plans usually cover hospital and medical expenses for an accident or illness. Some of them may also cover preventive care and office visits. These plans usually cover a percentage of your covered costs. Example: the plan pays 80% of your hospital stay and you pay the other 20%. With these plans, you are covered for any licensed health providers.

Sharing The Cost

Whether you choose a major medical plan, an HMO or a PPP, your plan will probably have some "cost-sharing" features. This means that you share the cost of care by paying part of the charge for each service and the insurance company pays the rest. Pick a plan that works best with the type of health insurance you think you will use. Different cost sharing features are listed below:

Copayment

A copayment is a fixed dollar amount that you pay directly to a doctor, hospital or pharmacy at the time you get service. Example, you pay $30 for an office visit and the plan pays the rest. A Plan may have different copayments for different types of services.

Example: 

The copayment for a primary care visit may be $30 and copayment for an emergency room visit may be $150.

Deductible

A deductible is the amount you pay before the plan starts to pay for most covered services. You usually must pay your deductible first, and then your other cost sharing begins, such as copays and coinsurance. 

Example:

You pay a $2,500 deductible toward your health care services each year before the plan pays any Coinsurance is a percent of the allowed charge that you pay for a covered service benefits.

Coinsurance

Coinsurance is a percent of the allowed charge that you pay for a covered service.

Example: 

You pay 20% of the cost of a covered office visit and the plan pays the rest.

Benefit Limit

Some health plans have a limit on the visits allowed for a specific covered service.

Example: The plan may allow only 10 visits to a chiropractor. 

Exclusion

Exclusions are listed services for which there is no benefit.

Example: The plan may exclude (not pay for) cosmetic surgery, and you will pay for the entire cost of service.

Out-Of-Pocket Maximum
An out-of-pocket maximum is a cap on your cost sharing for a year. Once your cost share amounts reach the out-of-pocket maximum, the plan pays 100% of the covered services for the rest of that year.

Ways To Get A Health Plan

There are many different ways that you can buy a health plan in Massachusetts. Many people get their health plan through their place of employment. For people that can't do this, there are several other ways to get a health plan.

Through Your Employer or Union

In Massachusetts over 70% of all employers offer health insurance as a benefit to their employees. Most of these employers pay part of the premium and also offer a choice of several health plans. You can choose the health plan that is best for you from the choices offered.

Qualified Student Health Insurance Plan (SHIP)

If you are enrolled as a student in a Massachusetts college or university, you can buy a health plan through your school. This SHIP id designed for students and is only available while you are enrolled. 

Directly from an Insurance Company

Massachusetts residents can buy health plans directly from an insurance company. And the company can't turn you down if you have a health condition. Sometimes the company will direct you to purchase their health plan through an intermediary. An intermediary is a company that takes care of the enrollment and premiums.

MassHealth

If you meet certain income requirements, you may be eligible for MassHealth. This is a Medicaid program paid for by the state and federal taxes for eligible persons. You can learn more at http://www.mass.gov/eohhs/gov/departments/masshealth/or call 1-800-841-2900

Through the Connector

If you do not work for an employer that pays at least 33% of your health plan premium, you may be able to purchase a health plan from the Connector. These are plans offered by Massachusetts HMOs that the Connector has picked to have good value.

You may be eligible for subsidies to help you pay the premiums, depending on your income. Any Massachusetts resident can enroll in a health plan during the annual open enrollment period. Otherwise, you may be able to enroll at other times during the year if you have special circumstances (qualifying events). For example, recently moving to Massachusetts or recently losing your health insurance.

Medicare

If you are over 65, or if you have a certain type of disability, you may be eligible for Medicare. You can learn more by calling the Social Security Administration at 1-800-772-1213 or Visit your local Social Security Office.

Other Government Health Plans

The state and federal government provide lower cost health coverage for certain people through public health programs. This includes the Indian Health Services, Peace Corps, CommonHealth, HealthyStart and other programs. You may call 1-800-841-2900 to learn more about these programs.

Additional Resources

Beware of Unlicensed Health Plans

When choosing a health plan, it is important to consider the differences between your options. Some plans provide more generous coverage, while others could leave you responsible for high medical bills. Shopping for health insurance can be overwhelming, but  remember, if the plan sounds too good to be true, it probably is. 


Discount Plans

Do not buy a discount plan as an alternative to health plan coverage. Discount plans charge a monthly fee in exchange for access to health care services at a reduced fee. These plans are not insurance and do not make any payments when you need health care services. Instead, they allow you to get a discount off of some of your medical charges. Discount plans may look like a cheap health plan, but they are not health insurance and they do not meet your Massachusetts "individual mandate" requirement for health coverage. You should check with your doctor or local pharmacist to ask whether you will receive any real savings before you give your money or your personal information to anyone offering health care discounts.

Health care sharing ministry plans.

These plans allow groups of people with a religious affiliation to share in the costs of certain specified health care costs. HCSMs are not insurance and not supervised by state insurance departments. Members typically pay a monthly fee that allows them to submit qualifying medical expenses for sharing with other HCSM members. There are not specific consumer protections that apply to these plans. They may not guarantee any payments, and they do not necessarily pay expenses for the same kinds of services that health insurance covers. 

 

Read the Fine Print Before Choosing a Health Plan

Always take a close look at plan benefits and limitations before you sign up or pay any fees. That way you can see in advance if the plan is right for you and your family. Ask what benefits the plan does and does not cover, what benefits have limits; ask whether the plan covers your prescription drugs; ask where you can view a list of the health care providers in the plan's network.

Remember to add up how much you will have to pay out of your pocket for deductibles and co-payments and items that are not covered. High out-of-pocket costs can soon wipe out the savings of lower monthly premiums. You should ask what is the monthly premium you would pay for the plan, what out-of-pocket costs will you have and whether there is a maximum, and what is the deductible.

Look for the Warning Signs of a Scam

Do not be fooled by bogus health plans selling on the internet or through unsolicited faxes or phone calls. You should always be careful when surfing the web. Review any website carefully and look for disclaimers such as "this is not insurance" or "not available in Massachusetts."

No Company Name or Address Asking for Personal Information
Beware of advertising that does not give the specific name and address of the insurance company offering the health plan. If the caller is unwilling to provide the exact name of the company, his or her name, where the company is located, or whether the company is licensed, or if they are a licensed insurance agent, you should just hang up.  Beware of telephone marketers who ask for your personal financial information in order to enroll you immediately. You do not ever need to provide financial information in order to get a quote. 

 

Limited Time Offer Pay First, Read Later
Beware of high pressure sales tactics that tell you a low monthly price is a limited time offer and will expire in a day or two.There is no such thing as a limited time offer or "special" in health insurance.  Beware of companies that will not provide any written information about the health plan unless you pay first.

 

When you do find a health plan that looks like it meets your needs, check the Division of Insurance website or call to find out if the company is licensed to sell that type of insurance in Massachusetts before you commit to buying the product. Be careful not to give out personal information or make a payment in response to an unsolicited fax or without checking it out first.

Remember: Stop. Call. Confirm.

If you are unsure about the insurance company you are dealing with, STOP before signing any paperwork or writing a check; CALL the DOI; and CONFIRM the company or agent offering insurance is legitimate and licensed in the state.

Additional Resources

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