Health Insurance

Health insurance is somewhat of an antiquated phrase these days. Health care plans would be a more accurate description of what you'll be choosing among. You will find that the differences between one health plan and another are in the levels of reimbursement they offer than in the types of care that they cover. For example, if you look at 10 different plans, they'll all cover surgery on an inpatient basis, but some may have 80 percent reimbursement above a $500 deductible, others may reimburse at 90 percent if a network provider is used and 70 percent if not, and still others may reimburse at 100 percent if the surgery is performed on an outpatient basis.

Common Coverages -- The expenses that you will find covered by health care plans are:

• treatment of illness, disease, or accidents
• medical, surgical, exploratory, therapeutic, or emergency care
• inpatient hospital room, incidentals, and treatment
• outpatient surgery and treatment
• doctor's office visits and treatment
• nursing services
• diagnostic care, such as x-rays, MRIs, or blood tests
• prescription drugs
• dental, vision, or hearing care, if required due to an accident or injury
• pregnancy and childbirth costs
• durable medical equipment purchase or rental
• specialty care, such as that provided in the Intensive Care Unit or Cardiac Care Unit
• mental health and substance abuse

Common exclusions -- The exclusions that you'll find in almost every policy are:

• work-related injuries covered by workers' compensation insurance
• services not recommended by a physician
• charges above those defined by the plan as reasonable and customary
• cosmetic surgery
• experimental procedures, drugs, or surgery

Certain dental, vision, and hearing benefits. The standard policy usually covers dental, vision, and hearing benefits only if the expenses are related to an accident or injury. Some states have specific rules about what coverages must be provided.

Effects of health care reform. The enactment of the Patient Protection and Affordable Care Act and related legislation requires individuals to have health care coverage or be subject to an assessment of a tax penalty. This mandate is in effect beginning in 2014. This requirement can be satisfied by a variety of methods, including obtaining health care coverage through an employer, purchasing health care coverage from an insurer or from a state exchange, or through participation in a government program such as Medicare. Federal subsidies are available for certain individuals below specific income levels.

In addition, health care reform heavily regulates the insurance industry, instituting benefit and coverage mandates. Except for grandfathered plans, it mandates that by 2014, all qualified health benefit plans offer at least an "essential health benefits package" as defined by the Secretary of Health and Human Services.

For more information, including the latest health care reform developments, visit the government's health care website.

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