DENTAL coverage is not part of the medical health insurance plans; it may be purchased as an additional service, or as a stand-alone plan.
Health insurance systems:

HMO
The HMO considered being the most affordable system. The insured has to select a Primary Care Physician (PCP) doctor from the plan's directory. The PCP has the authorization to refer patients to specialists, hospitals and other service providers. If a patient seeks for a service without the PCP authorization he/she may end up paying very high cost for this service, as the insurance carrier may not cover it.

Advantages:
1. Relatively lower cost for major health services.
2. Good HMO system has the fine balance between cost and services.
3. Most billing and payment matters to health providers are taken care by the HMO management. There is no need for frequent contact between the insured and the insurance company.
4. Patients may not check before each office visit if their PCP is with the Insurance IN NETWORK directory. If the PCP office is terminating the relationship with the insurance company, they tend to notify the insured with the change.

Disadvantages:
1. Limited health services. Insurance carriers tend to exclude high priced services and new drugs from the HMO systems.
2. Patient cannot see a specialist without the PCP authorization. This process is not always in the best interest of the patient.
3. The IN-NETWORK doctors' directory is changing frequently. Insured may not be able to get service from the same doctor for long time. Doctors may choose not to participate with the HMO IN_NETWORK system if it pays less than the PPO plans.

PPO (Preferred providers Organization)
The PPO is a system that allows insured to choose their doctors and health facilities. The monthly premiums are typically higher compared to the HMO, but it has major advantages over the HMO system. As with the HMO, the IN-NETWORK doctors and services are the most cost effective.

Advantages:
1. Insured are free to choose their doctors and health care facilities from the PPO IN-NETWORK directory.
2. Most doctors prefer to work with PPO networks, their contacts with the health insurance companies paid more compared to the HMO.
3. More drugs and high priced services are covered under the PPO system.
4. The fact that insured can choose their doctor may save them time and money by getting service from specialists at the first time.

Disadvantages:
5. Insured have to deal directly with their health insurance and service providers for billing issues. It takes time and effort to manage all the payments matters.
6. Insured required checking before each office visits if the healthcare provider accepts their insurance. In case that the service was not covered, or the service provider was OUT-OF-NETWORK, it may be resulted with high medical bills.
7. PPO monthly premiums typically cost more compared to the HMO plans.

Health Coverage types:
1. Group Insurance
1.1 Group health insurance is the best plan for most insured. In general no proof of insurability is required to participate, where many insured may not be covered otherwise. Under group plans the cost of services is negotiated to be the lowest and the coverage is considered good
1.2 Plans may or may not offer coverage for family members of the insured. It is up to the group administrator or the employer benefit department to set the coverage policy
1.3 Most group health plans cover medical services and prescription drugs. Dental and Vision coverage may be offered as an additional benefit.

1.4 Employers/group administrators may pay part of the premium cost as a benefit to the group members, where the insured pay their share of the cost.

1.5 When insured terminates the relationship with the group, a special law allows keeping the group plan with same coverage for a certain time. The insured has to provide with the full premium cost.

2. Individual health insurance
Individual health insurance is the alternative to the group health insurance. It is offered to individuals and their families under certain conditions.
Typical characters of individual health insurance are:
2.1 The cost of individual plans may be significantly higher compared to group insurance plans, for the same coverage
2.2 Prescription drugs may be offered with additional cost
2.3 The proposed insured has to be medically qualified for the individual plan. Pre-existing conditions (smoking, chronic diseases, medications taken, over weight, pregnancy and many other conditions) may result in higher premiums or rejection
2.4 If insured, pre-existing conditions are typically not covered for certain time or may not be covered at all.
2.5 Higher deductible fees are likely.
2.6 If there is a gap in health insurance coverage, it may result in rejection.
2.7 Health insurance may terminate coverage or raise premiums under the local state regulations to insured with recently diagnosed medical conditions

Drugs coverage:
Each insurance company has a list of covered drugs divided into internal priced-level groups. Those drugs may be purchased by prescription only. For each drug there is maximum doze allowed for a certain period (typically 1 month or 90 days).
If the doctor prescribed refills to the drugs, the insured may get the refilled drug without the need to re-visit the doctor
Prescription drugs benefit is included in most insurance plans, otherwise it may be added as an option with additional cost.

Insurance Premiums and Payments
Health insurance services and premiums are a major expense for most families in the US. In the recent year the average increase in cost was over 10% every year. As a result insured pay more for premiums for services and drugs. Employers tend to shift their cost to the employees as well as terminating coverage for high prices services.
It is very important to confirm coverage before seeking health services; otherwise the insured may be liable for very high medical bills.

Payments and fees associated with the health insurance:
1. Premiums: The cost for the health insurance.
For group members a payroll deduction may be available. This payment is deducted pre-tax. Employers/Group administrators may pay portion of the premium as a benefit to the group member.
For individual members: A monthly premium is required to the insurance company. Good health insurance plan for a family may cost around $1,000 a month.

2. Deductible:
The amount that insured pays every time that he/she seeks for a service. The deductible is based on a fee schedule and could be anywhere from $5-45 for doctor office visit, to $30-100 for hospital's emergency room.
In some health plans the insured has to satisfy the deductible amount before the insurance pays its share. This deductible amount may be $500-2500 for individual and $5000 or more per family each calendar year.
3. Co - Insurance:
The share that the insurance covers after the deductible amount is met. As an example the health plan is 80/20 with $25 deductible. After the insured paid the $25 deductible, the insurance will pay 80% of the rest of the cost. The insured is liable for the additional 20%.
4. Prescription drugs:
There are many ways how the insurance companies charge for drugs.
One common way is to define 3 groups: generic, medium level and Brand. For each group there is different price.
Another common practice is to charge a percentage of the drug's cost.
5. Maximum plan benefits:
Each health plan has a "maximum life benefits provision". This is the maximum amount that insurance companies may be liable for the entire length of the plan.
6. Fee Schedule:
The negotiated amount that insurance carriers pay to the health providers for their service. Deductibles and co-insurance payment are based on this fee schedule.
Patients may pay significantly more for the same service if not covered by health insurance.

Amir Mushkat is a licensed Israeli health insurance agent in the US
For more information please contact 301-816-9079 or email : amushkat@myrealbox.com.

Amir Mushkat is an Israeli loan originator in the US.
For advise please contact : 301-816-9079 or amushkat@myrealbox.com
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