Frequently Asked Questions

There are many questions that individuals have regarding health insurance. This is because the insurance purchasing process involves many people, from the customer and the agent to the underwriter and insurance company. For the average individual, it is easy to become baffled by the process; here are some answers to questions we thought were relevant to choosing the right plan.

What are the Ways that Individuals receive Health Insurance Protection?

Besides participating in group insurance plans, individuals may also be covered under federal and state government-sponsored programs such as Medicare and Medicaid, service-type plans such as Blue Cross/Blue Shield or so-called alternative health care systems such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Insurance may also be purchased privately on an individual basis, or through mass purchasing groups such as credit unions and professional or trade associations.

Do Health Insurance Plans cover Dental Care?

Proper dental care has been considered a budgetable expense, so it has not been included in group health insurance plans. In the 1970s, as its cost increased, dental care was added to employee benefits plans. Some plans include dental coverage as part of the medical plan; others include dental coverage as a separate plan. However, many health insurance plans do provide coverage for non-cosmetic dental work necessary as the result of an accident. Some plans include limited coverage for hospital room and board expenses related to dental procedures, such as removal of impacted wisdom teeth, performed in a hospital.

How is Vision Care Covered?

Most health insurance plans provide coverage for medical care related to eye injury or disease, but do not cover the costs of periodic eye examinations or corrective lenses. Like dental care, vision care is a relatively new employee benefit, offered by employers that can afford to expand their employee benefits plans to include additional fringe benefits previously considered budgetable. Vision care is most often covered on a scheduled basis that pays a fixed dollar amount for examinations, lenses and frames. Vision care is almost universally noncontributory due to the potential for biased selection.

Are Prescription Drugs Covered under Health Care Plans?

Generally, only prescription drugs that are for treatment of an illness or injury are covered, subject to applicable deductibles and coinsurance. Many plans do not cover contraceptive prescription drugs, for example, or nicotine chewing gum prescribed for smokers who are trying to quit.

Are there Different Types of Drug Plans?

There are a number of variations, but the principal types of prescription medication plans are open panel, closed panel, mail order and prescription drug card plans

What is the Major Difference between Group and Individual Insurance?

The major difference between group and individual health insurance involves evidence of insurability. To purchase individual insurance, a person must generally answer a health questionnaire and undergo a medical examination to provide evidence of insurability to the insurance company. An insurer may decline coverage on the basis of the applicant's personal habits, health, medical history, age, income or any other factors that bear on risk acceptance. Or the insurer may issue a policy with limitations on coverage. Most group insurance, however, is issued without medical examination or other evidence of individual insurability because the insurer knows that it can cover enough individuals to balance those in poor health against those in good health. The risk of an insurer failing to achieve this balance is diminished as the size of the group increases, or as the insurer underwrites additional group policies and increases the total number of individuals covered. This is known as the "law of large numbers."

What are the Advantages of Group Insurance over Individual Insurance?

For an employer that intends to provide insurance protection to its employees, the group approach ensures that all employees, regardless of health, can be covered. Those with known health problems, who might otherwise be unable to obtain individual insurance, can be covered automatically upon employment without evidence of insurability. Although some limits may be imposed on new hires for certain conditions that predate their enrollment in the plan, most employees can receive coverage as soon as they are eligible. Group insurance offers a lower cost per unit of protection than individual health insurance, because the economies of scale resulting from selling, installing and servicing one plan covering many individuals. In addition, group plans are typically more flexible and tend to provide more liberal benefits than individual coverage

Who is an Eligible Employee?

An eligible employee is any employee who meets the definition in the plan for participation. Definitions of eligible employee vary widely from employer to employer, though they may be influenced by legal considerations and company structure.

What is a Base Plus Plan?

A base plus plan is a two-part health insurance plan. Basic medical coverage -- for such expenses as hospitalization, surgery, physician's visits, diagnostic laboratory tests and x-rays -- is provided under the first part. There may be limits on these expenses, such as a limited number of hospital days and a surgical schedule, but no deductible or coinsurance applies to the covered expenses. The employee is reimbursed starting with the first dollar of expenses. The second, or major medical, part of the plan covers other health expenses. The coverage is broad, with fewer limits; however, a deductible is required before the employee is reimbursed for expenses.

What is a Comprehensive Plan?

A comprehensive plan provides coverage for most medical services using one reimbursement formula. In a pure comprehensive plan, a deductible must be met before reimbursement for any covered expenses begins, and coinsurance applies to all covered expenses until the maximum employee out-of-pocket expense limit is reached. Additional covered expenses are paid in full. Because employees share from the beginning in the cost of their medical expenses when they are incurred, a comprehensive plan encourages them to use more cost-effective health care. The patient is more likely to be cost-conscious and to seek out more cost-effective health care services and providers.

What is Co-Insurance?

Coinsurance is a feature found in most group health insurance plans. It sets forth the percentage of covered expenses that the employees and the health insurance plan will pay. The most common coinsurance level is one in which the employee pays 20 percent of the expenses and the insurer pays 80 percent. This is called 80 percent coinsurance.

What is a Covered Expense?  Are there limits?

A covered expense is an expense incurred by a covered individual that will be reimbursed in whole or in part under the group health insurance plan. For example, under most health insurance plans, doctors' visits are a covered expense. That is, a doctor's fee up to the amount provided by the plan will be reimbursed by the insurer Just because an expense is covered does not mean that the coverage is unlimited. Both base plus and comprehensive plans have limits on the expenses for which they will reimburse. In addition, some form of deductible and coinsurance is often applicable. Insurers limit covered expenses in a variety of ways. One way is to cap allowable payments for a certain procedure or service. A common example of this type of limit would be a surgical schedule. Insurers also restrict covered expenses by limiting the number of visits or days for home health care or skilled nursing care.