The ABC’s of health insurance
HMO, PCP, PPO, POS — feel like you’re wading through alphabet soup? Read on for translations of common terms.
• Health maintenance organizations (HMO) require you to choose a primary care physician (PCP), who coordinates all of your care, including visits to specialists.
• Preferred provider organizations (PPO) let you make your own choices from a network of preferred providers (in some plans, you can pay a higher fee for out-of-network care) and may not require you to have a primary care physician.
• Point-of-service plans (POS) let you choose between receiving care from participating providers (you’ll be reimbursed more for this), or non-participating providers(you’ll be reimbursed less for this).
Some plans offer lower premiums (monthly payments) in exchange for a higher yearly deductible (the amount you must pay personally before insurance provides any coverage). Some plans require co-pays, a set fee you pay for health care visits or medications. Others ask you to pay co-insurance, which means you’re responsible for a portion (20 percent, for example) of eligible expenses charged by a provider or the amount the insurer agrees to pay for specific services.
Many plans require preauthorization or precertification for certain services, such as surgery or visits to a specialist. Some pick up the tab on preventive care services, such as flu shots, cholesterol tests, or colonoscopy. Most have formularies that list pre-approved, commonly prescribed drugs.
Making every dollar count
“Until the economy bounces back, people will be looking for ways to cut costs wherever they can,” said Dr. John Fallon, Chief Physician Executive at Blue Cross Blue Shield of Massachusetts (BCBSMA). “But when it comes to our health, we have to be smart about the decisions we make, including how we select and use our health care plans.”
Whether you sign up for a health plan through work or on your own, being a smart consumer is key. Carefully evaluate all the options available to you to find the best care for your money.
Compare available plans during open enrollment periods.
Carefully compare all available options during annual open enrollment periods (often in the fall); sticking with the same plan doesn’t always make sense. If you don’t anticipate needing to see the doctor frequently, it may be worthwhile to select a less expensive plan with higher co-pays or a higher deductible. Most health plans have formularies listing pre-approved drugs. Often, drugs are added (and sometimes dropped) annually. Remember to check formularies annually for medications you need. Staying informed — and keeping on top of selection deadlines — can save you headaches and cash.
Compare additional incentives. Many plans offer discounts for health club memberships, smoking cessation, weight loss programs and preventive screenings. Discounts may even apply to accredited complementary care providers you visit, such as a dietitian, chiropractor, masseuse, or acupuncturist. Blue Cross Blue Shield of Massachusetts offers this through the Living Healthy Naturally Program. Once you find the right plan, follow these tips to save on costs:
1. Investigate health savings accounts. If you’re under 65 and have a high-deductible plan, you can put a portion of pretax dollars into a Health Savings Account (HSA) to pay for eligible health expenses, thus lowering your tax bill. Unused HSA funds can roll over and accumulate year to year. Alternatively, a Flexible Spending Account (FSA) offered only through employers holds pretax dollars for eligible health or dependent expenses. FSA funds not spent by year-end are forfeited. If you already have an FSA, remember to submit 2009 claims for reimbursement by March 31, 2010.
2. Stay in network. Use doctors and specialists in your health plan’s network. Out-of-network care drives up your share of the health care bill. If you’re unsure if a provider is in your plan’s network, simply give your plan a call or check online.
3. Save on prescriptions. Always ask about generics, lower-cost brand name medications and over-the-counter options. Generics, which can be as effective as brand name counterparts, come on the market frequently (and big chains like Kmart, Sam’s Club, Target, and Wal–Mart price hundreds of generics under $5 for a 30-day supply). Find out if lifestyle changes — more exercise, better diet, stress reduction — might lower dosages or erase need for some medication. Always talk to your doctor or pharmacist before making any medication changes.
4. Dial a help line. Find out if your plan has nurse help lines to advise you on whether you should see a doctor or can self-treat using simple remedies like fluids, fever-relievers and rest. For example, members who have a plan under BCBSMA can call experienced nurses staffing the 24–hour Blue Care Line. Often a call can save an unnecessary trip to the hospital or doctor’s office — and your co-pay. Ask your plan what resources may be available to you.
5. Participate in wellness programs. Hit the jackpot with healthy choices. Exercising, losing weight and quitting smoking dramatically lower your risks for asthma, diabetes, cancer and heart problems, significantly improving your health while cutting your health care bills. Many health plans offer wellness program discounts, rebates and fabulous online tools like personalized weight loss or workout plans. Free and low-cost community programs may be available through the Boston Parks and Recreation Department, senior centers and community education centers.