Seniors turning 65 typically look to Medicare for their insurance needs. However, with the advent of Advantage plans, there are more choices than ever. This can be difficult to navigate and understanding the differences will lead to the best choice for an individual.
FIRST THE BASICS
Most insurances pay for medical services, covering a large portion, usually 80 percent. The remaining 20 percent is often covered by a supplemental policy or secondary policy. If someone does not have a secondary policy, that portion’s responsibility falls on the patient. Sometimes insurances won’t pay the full amount of a medical bill, and that portion could also be the responsibility of the patient.
IN NETWORK AND OUT OF NETWORK
This could be important depending on the type of insurance one has. Certain insurance plans known as PPO or Preferred Provider Organization could cost more but allow the patient more options for their care, as it has a broader coverage. HMO or Health Maintenance Organization is typically a cheaper option but limits care to only those physicians, hospitals, and other services that participate in that specific HMO. For an HMO, having “in network” care allows for the most cost-effective option, but limits where you can go for your care. PPO’s provide greater flexibility, but your premium could be higher.
Most insurances have a deductible or an initial portion a patient is responsible for before the insurance coverage starts. This is also true for Medicare at the first of each year. Regardless of insurance type, most plans have a deductible structure, so make sure you are aware of your out-of-pocket responsibility.
EOB, EXPLANATION OF BENEFIT
We get questions about EOBs or Explanation of Benefits from time to time. EOBs are complex paperwork provided by the insurance company to patients, stating the care received. For any questions regarding an EOB, always ask for an explanation from your healthcare provider as this is unique to the specific care provided.
WHAT SHOULD YOU CHOOSE?
Health insurance, like any other insurance, is a necessary part of life. There are unique and personal considerations you should factor in deciding the type of insurance right for you. For those remaining local, an HMO plan may be more cost-effective, but remember the more health care needed, the most your out-of-pocket cost could be, even with initially lower premiums. If you need flexibility or physicians that don’t participate in HMOs, then a PPO plan would be more suitable.
Hansa Medical Groupe has offices at 5250 Old Orchard Road, Suite 300, in Skokie, and in Chicago, 847-920-0902, hansamedicalgroupe.com.