|
|
Frequently Asked Questions
Issues Addressed In These FAQs:
- Why buy medical insurance?
- What is the difference between a primary care
provider (PCP) and a preferred provider
(sometimes referred to as a particpating
provider)?
- What are the differences between plans?
- I'm self-employed - am I covered while I'm
working?
- Can I buy individual policies for the
employees of my small business?
- My significant other and I are not married -
can we be insured together under one policy?
|
1. Why buy medical insurance?
|
 TOP
|
|
People buy medical insurance to protect against the risk of
financial ruin as a result of a catastrophic accident or
illness. If you have assets, you need medical insurance - one
of the most common causes of bankruptcy is uninsured medical
expenses.
|
|
2. What is the difference between a primary care provider
(PCP) and a preferred provider (sometimes referred to as
a participating provider)?
|
TOP
|
|
A primary care provider
(PCP) is usually a physician
(or other approved provider) that you select from the
insurance company's list of primary care providers at
the time of enrollment. Normally all your care must
be received from that PCP or a provider you are referred
to by your PCP. A preferred (or participating) provider
is one who is on the company's list of preferred (or
participating) providers. You do not have to select
a specific doctor ahead of time and in fact you can
choose to receive care from providers not on the
list, however you will not receive as high a level
of benefits as you would if you utilized a
preferred (or participating) provider.
|
|
3. I don’t understand the differences between Major
Medical plans, PPO plans and HMOs.
|
TOP
|
|
MM (Major Medical) plans traditionally give you
the greatest freedom of choice in choosing a doctor or other
medical provider but increasingly are becoming the most
expensive type of plan. Each insured generally must meet a
deductible before any benefits are paid, then the insurance
company reimburses eligible expenses at a specified
percentage rate (the coinsurance).
Generally, after a specified level of expenses
(the stop-loss)
have been incurred, the insurance company will reimburse
100% of eligible expenses for the remainder of the
calendar year.
|
|
PPO (Preferred Provider Organizations) plans
are similar to traditional major medical plans except the
coinsurance rate will differ depending upon whether you receive
treatment from a provider (doctor, hospital, etc.) on the
insurance company’s "preferred list" or not.
Non-preferred providers are reimbursed at a lower rate.
You are still free to use any doctor and you will receive
at least some level of benefits even if you don't use a
provider from the preferred list.
|
|
HMOs (Health Maintenance Organization) restrict
your choice of providers the most but generally also give you
the lowest out of pocket costs for your medical care. You must
choose a Primary Care Provider (PCP) and all your medical care
must be coordinated through your PCP - if you don’t go
through your PCP that treatment will usually not be covered.
There are no deductibles and services are covered at 100%
after a co-payment by you.
|
|
In reality the lines between the different types of plans are
blurring with many plans having some elements of more than
one type. It is not uncommon to see PPO plans that have a
co-pay with no deductible for doctors on their preferred
list or HMO’s that allow you to self-refer or go outside
the HMO provider panel and still receive some benefits
(though usually at a substantially reduced level). These are known as Point of Service (POS) plans.
|
|
4. I’m self employed - am I covered when I’m working?
|
TOP
|
|
Most plans will cover you while working if you are not covered by
Worker’s Compensation, but you would be well advised to double
check with your health insurance company to make sure.
|
|
5. I own a small business - can I buy individual
policies for my employees?
|
TOP
|
|
Generally no. Oregon law requires different underwriting
standards for group insurance and defines groups as two or more
employees (including the owner of the business). Thus if you
have one or more employees in addition to yourself and you
are paying for some or all of their medical insurance,
you automatically are considered to be a group.
Insurance companies will not knowingly issue
individual policies in such a situation and most will
require an individual policy applicant to state their
employer is not paying the premium. To receive a quote for
your business, please go to the
Group Plans
page and follow the instructions.
|
|
6. My significant other and I are not married
- can we be insured together under one policy?
|
TOP
|
|
Generally no. In Oregon such arrangements are not recognized
as a basis for joint coverage under individual medical
policies. |
|