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Health Insurance Plans: 4 Things You Should Know

4 Things You Should Know

Health Insurance Plans: 4 Things You Should Know

Choosing a health plan can be confusing, but choosing the right plan for your needs is important. The Division of Insurance has some tips for you consider as you go through the process of choosing a health plan.

Major Types of Health Plans
Most health insurance plans fall into one of three categories. In order to choose the best plan for you and your family, you should understand the difference between these major types.
Health Maintenance Organization (HMO)

HMOs have a network of providers that you must use in order to be covered and not pay additional costs. If you have doctors or another provider that you use now, you should be sure they are in the network before you enroll in the HMO. Also, an HMO's network of providers are located within the HMO's "service area." If any family members you want to cover do not live in the service area, an HMO may not be a good choice for you.

Preferred Provider Plan (PPP)

PPPs also have a network of providers, but (unlike an HMO) will cover and pay for services for out-of-network providers. The benefits are usually greater for the network providers. If your usual providers are in the network, but you want to have the option to go to other providers, a PPP may be a good choice.

Major Medical or Indemnity Plans

These plans cover services with any licensed health provider. This may be a good plan if you have family members outside the HMO's or PPP's service area, or if your providers are not in the network.
Choose the Plan That Best Fits Your Needs
Think about the types of services that you and your family will use and how often they will use them. If you and your family expect to mainly use preventive care services, you might be happy with a plan that has a higher deductible but will cover preventive care before the deductible. However, if anyone has a condition that will require access to lots of services, you may want to choose a plan that has no deductible, but has fixed dollar copayments for each service.
Determine the Cost

Your cost sharing (deductible copayments, coinsurance) plus the premium will be the total cost of your health plan.
Understand Your Health Plan
Once you have enrolled in a health plan, be sure you understand your plan. When you enroll you will be given a certificate or evidence of coverage. The insurance company may mail a copy to you or they might give you the access to it on a website. If you have a health plan through your employer, the employer will have information on your plan. Read your certificate and keep it handy to look at when you use health services. Be sure to read and understand the following:

Know Your Benefits and Exclusions

Be sure you know exactly what your plan covers. Not all health plans cover the same services in the same way. Your certificate will list all of the services that are covered under your plan. It will also tell you if any services have limitations (such as maximum amount that they will pay for durable medical equipment or physical therapy). And it should tell what services are not covered at all (such as acupuncture).

How to Access Services

The plan certificate will tell you if you need to use network providers to be covered. It should tell you if you need to have the health plan authorize care before you see a provider. It should also tell you:

• If you need to have the plan authorize care before you see a provider
• What to do in case of an emergency
• What to do if you are hospitalized

Remember, the health plan may not pay for your services if you did not follow the procedures.

Know Your Rights

The certificate tells you all your rights when you seek services and how to file an appeal when you don't get the coverage you think you should. Massachusetts provides many protections for insureds that your certificate will describe.

Remember - A Health Benefit Plan is an Insurance Policy

An insurance policy is a legal contract that describes the promise an insurance company makes to pay certain benefits in return for a premium payment.

Insurance is not a bank account in which your premiums are stored; it is a legal promise that the insurance company will pay for the costs of certain identified losses that may occur during the policy period. Likewise any health benefit plan you buy or enroll in protects you while you are enrolled in the plan.

To choose the right health plan and to make sure that plan works for you, take time to review all of your options and understand what each one means.

Always Read Your Policy

It is up you to make the best decision for you and your family. It is very important that you read your certificate or "evidence of coverage" carefully to understand what is covered and what you need to do before you enroll. Then, once you are enrolled, review it again before you access services.

Contact the Division of Insurance

If you have questions about health insurance, contact the Division of Insurance by calling our consumer hotline - 617-521-7794 - or visit our website at

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 your state insurance department - easily reached by phone; and CONFIRM the company or agent offering insurance is legitimate and licensed in the state.