Here are some powerful tips intended to help you obtain comprehensive coverage and to avoid potential gaps and costly surprises.
1. Look for the term - Major Medical - in writing!
In general, a "Major Medical" or "Comprehensive Major Medical" health plan covers medically necessary treatment unless specifically excluded. On the other hand, a "Basic Medical" or "Hospital/Surgical" typically covers only treatment that is specifically included on a schedule of benefits.
Look carefully at the difference. "Basic Medical" or "Hospital/Surgical plans serve a purpose and their premiums are usually lower. However, if you qualify and you want the most comprehensive protection, look for the words "Major Medical" or "Comprehensive Major Medical" on the offering brochure or policy.
2. Check how a health plan will pay your medical claims. Look for the term "Reasonable" as well as "Usual and Customary".
Sometimes, insurance companies will pay for medical procedures based on a schedule of fees that are considered to be the "Usual and Customary" for the region. However, if an unexpected complication occurs and reasonable, extra services are required during a medical procedure from a doctor or hospital, these reasonable, extra services may not be covered under the definition of "Usual and Customary" alone.
Complications can be costly, sometimes very costly! Look for the term "usual, reasonable, and customary" for greater protection.
3. When comparing health plans, check the "Exclusions" first.
One of the first things an experienced agent looks at in a health insurance plan is the list of plan exclusions, or what is NOT covered. Often found in small print, what is NOT covered is equally as important as what IS.
Many exclusions are typical (i.e. acts of war, self-inflicted injuries, custodial care, etc.), while others are not and should be carefully considered when comparing health plans. For example, does the plan have a waiting period for certain conditions? One exclusion of a "Basic Medical" or "Hospital Surgical" plan is "anything not specifically listed in the policy."
4. If you have a favorite doctor, does he or she participate in a PPO network?
Lower-cost health plans control costs by contracting with a "Preferred Provider Organization" or "PPO." If you have a favorite doctor who is important to you, call your doctor's office and ask in which PPOs your doctor participates. Save yourself time by only comparing those plans that offer your doctor's PPO network.
You will find links to PPO Networks on our Florida Doctors page.
5. Activate your memory when completing the health questionnaire. Here’s why:
The final step in obtaining health insurance is qualifying through the health questionnaire. It’s important to remember that by nature, the human mind tends to forget or minimize past or present illness. A positive attitude can be a benefit in the healing process. However, failing to disclose a material health condition, past or present, could jeopardize your coverage entirely.
Medical audits are often done when there is a major claim. By contract, the insurance company can revoke coverage and return all premiums if it can be shown that the policyholder failed to disclose a material condition on the application.
Never give the insurance company a potential way out of paying a major claim. Even though this is the last step in the process, don’t be hurried.
Disclosing past illness or injury is not an automatic negative. When truthful, always include clearly written phrases such as "complete recovery", "no further treatment", and "well controlled." It helps to clearly state the positive in writing.
6. Be sure you "look your best" for the insurance company medical exam.
After applying for health insurance, you may be asked to take a brief "paramedical exam." If you are over age 50, you can count on it.
This exam is normally paid for by the insurance company and is conducted by a licensed nurse or paramedic. The examiner will usually come to you. It is generally best to schedule your exam in the morning before eating. For additional information, see Save $ Tips - Paramedic Exams For Health Insurance
7. Lower your premium with a higher deductible.
The primary purpose of insurance is to cover the BIG expenses. Most financial experts recommend lowering your premium by electing a higher deductible, while maintaining comprehensive Major Medical protection.
8. Understand why certain health insurance plans are "cheap."
While comparing price is easy, you should always be aware of the differences in coverage which account for differences in price. When comparing plans, here are some differences you may encounter.
| Lower Premium | Higher Premium |
| $2,000,000 in total coverage | $5,000,000 in total coverage |
"Co-insurance"
After deductible, you pay 20% of the next $15,000. ($3000) | "Co-insurance"
After deductible, you pay 20% of the next $5000. ($1000) |
| Limits on coverage for items such as intensive care, organ transplants, mental health, and air ambulance. | Fewer limits on medically necessary treatment. More overall coverage. |
| Reimburses medical expenses which are "Usual and Customary". | Reimburses medical expenses which are "Usual, Customary and Reasonable". |
| Basic Medical Plan or Hospital/Surgical Plan with broad medical exclusions. | Comprehensive Major Medical Plan with fewer exclusions. |
| Click Here to Compare Health Insurance. |
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