Health Insurance and you: Part I

Health insurance. Love it or hate it, you have to admit it's a lot cheaper than getting sick without it. So, how do you get the most out of your health insurance? I will give you some hints. However, this subject will require you to do your homework.

First: like all good teachers, homework gets assigned first. Find out from your employer (if you don't already know) exactly what type of insurance you have and what it covers. Ask for a handbook, if you don't have one, and read it. You may have to go to your Human Resources department for the information. If they don't have a hard copy, ask if they have soft copy. If they don't, ask them to get one for you. READ IT. It will answer many questions you may have. (And you would be amazed at the number of people who have never looked at the information and are then VERY upset that something isn't covered).

A little secret that employers don't tell you: when they contract for health insurance, it's rather like the old Chinese menu joke: you pick from column A and column B and with 6 you get egg roll.

Health Insurance (HI) is like that. Basically, a HI company will give your employer anything it wants to offer to its employees, for a price. However, as usual, the federal and state governments have something to say about it, too. Depending on factors discussed below, there are minimum requirements that the HI company HAS to offer and your employer has to pick (AKA Column A). Then comes the fun part: what pieces can they CHOOSE to pick (AKA Column B)? This can vary depending on several factors: how many employees are there? What does the state require a company of your size to offer? Does your company want to be a "self-funded" group, if allowed by the state, or "fully-insured"?

What's the difference?

Self-funded groups basically work on a "pay as you go" method. They pay the insurance company varying amounts depending on the cost of the claims received that month (along with a processing fee). So, the amount will vary from month to month as to what your employer pays (not what you pay, if you contribute).

Fully-Insured groups pay a set fee every month. It does not matter what was paid out in claims- $0 or $1,000,000 - the company pays the same amount every month. This can be easier for the company to figure cost-wise, but it has some problems.

One reason is this: in many states, self-funded accounts are often allowed to "opt-out" of benefits that the state requires fully-insured groups to offer to their members. This drives up the costs for fully-insured groups (and is often a reason given for groups to change from fully-insured to self-funded; it's a cost containment measure). For example, certain benefits regarding the treatment of children with autism are mandated by my state. Self-funded accounts can decide not to follow the mandate and offer more or less (or none) of the services the mandate requires.

Next, we have the products issue: does your employer want to have only one type of insurance? What kind - managed care (like an HMO, POS plan, etc) or a traditional plan? Do they want to offer several kinds of plans? Do they have to/want to cover spouses, children, domestic partners? All of these things may be options or may be required by your state.

What's the difference between managed care and traditional ?

With managed care, most plans require you select a Primary Care Physician (PCP) who can be a pediatrician (for children), a family practice doctor (all ages the MD wishes to care for), or an internist/internal medicine doctor (typically an adults-only practice). This doctor acts as a general "gatekeeper" who sees you and decides if you need specialty care or not, and refers you to a specialist if you do. Generally, you need to stay "in-network" (IN) for all of your care for the best benefits. Most HMO plans do not allow a member to go "out-of-network" (OON) for care unless there is no IN specialty provider within a certain range of transportation. POS members may go OON but will have to pay more if they do so.

With most "traditional" type plans you can see any physician you choose, no matter what specialty, without a referral from your "regular" doctor (if you have one). If you belong to a PPO or standard traditional plan, you get better benefits if you see an IN provider but no referrals are needed.

IN providers: what are they? Basically, they are physicians (individual or groups) who have signed a contract with your HI provider for set fees. As a patient, you generally pay less if you see an IN provider. You often only have a "co-pay" amount for an IN provider, and, if the insurance company pays less than the provider charges (a common situation), the provider cannot "balance-bill" you for the difference.

OON providers: Obviously, doctors who are not contracted with your HI provider. They are not held to the fees an IN provider has agreed to, and they often can "balance-bill" you - which means after they receive the payment from your insurance company, they may bill you for the remainder of the amount they charged for your care.

Example: Jan has a "copay" of $10 if she goes to see an IN provider for care. When Jan goes to see Dr A, her IN provider, she pays $10 no matter what Dr A charges. However, Jan has been unhappy with Dr A lately; she feels he isn't helping her. She decides to visit Dr B, whom her BFF absolutely loves (and who belongs to BFF's insurance plan). Unfortunately, Dr B is not a participating (PAR) provider with Jan's insurance. Jan's policy states that when she sees a non-participating (NON-PAR) doctor, her insurance will pay 80% of "reasonable and customary" (R&C) charges and she will be responsible for the remaining 20% of R&C, and the difference between the charges and what is paid by insurance (balance-billing). Jan sees Dr B, who charges $300 for the visit. Jan's HI has decided (based on several components, one of which is 'What does Medicare pay for this?") that the R&C for the visit type Dr B billed is $100. HI pays $80, and Jan is responsible for the remaining $20 of the R&C fee, AND the additional $200 if Dr B decides to balance bill her.

Well, enough for tonight. Do your homework and enjoy the next part:

Part II: How to make friends at your Health Insurance Company

Quick Picks

I'll have more to post later but the snow calls for a shovel so it probably won't be tonight.

Sane Mom mentioned in the comments the post by Lisa Belkin "Seeing All Men as Predators". I read that when it came out because Lenore Skenazy mentioned it in her blog "Free Range Kids" (listed on the side bar). She has a lot of good information (and a book) about raising your kids in today's society without fear. My kids were pretty free-range. They walked to/from school, rode bikes to friends, went to the park and played. And they weren't kidnapped, molested, or harmed in any way (well, scratch that. My eldest has scars from falling off her bike 2 blocks from home and walking home, knee bleeding profusely, crying. But she made it home, with the bike, and in the house before I knew anything had happened).

I just got a list of items that per the Health Insurance Act, should be covered by insurance. Unfortunately, I left it in the office. Sorry! I'll review it later.

Speaking of insurance, I would be happy to write a post on how to make friends and influence the people at your health insurance provider if people would like to read it. (Yes, I DO work for the dark side of the force, why do you ask?)

Last on the agenda: a discussion about breast is best or bottle is better. I have my reasons for wording it that way, which I will explain in the post.

Comments and post suggestions are welcome. And if you have something you want to post for feedback, let me know and I'll happily add you as a contributor.

Edit: I turned off the sign in feature so those who want to post comments don't have to sign in. Capcha will remain off for now because I really don't like capchas, but if the spam gets back one or the other will be set up. I'll ask for opinions before I do that though.

Gee, what do I say?

It occurred to me that people might wonder what they can say here, so I thought I'd give some life examples that they can start with.

Back in the day, pediatricians recommended you give tylenol to your baby 30-45 minutes prior to your vaccination appointment. Now, I've heard they don't do that. True? What has your pediatrician told you?

My child vomiting, for me, was the worst thing to deal with. I would generally retch in harmony with them, as I cleaned up their bodies, hair, faces, beds... It was always the odor, not the sound or appearance of the vomit. However, like all parents, I coped and tried to make them feel better. One "tried and true" treatment has been handed down in our family for 60+ years and we still use it.

Whenever a child vomits, the clock starts, and they may have nothing by mouth for 4 hours. Once that 4 hours is up (and the child is awake), the child may have 1/4 teaspoon of FLAT ginger ale or coke. If they keep that down, it may be repeated in 15 minutes. Repeat for an hour; if no further vomiting then the amount may be slowly increased to 1/2 teaspoon, after another hour 1 teaspoon, after another hour, sips. However, if the child vomits again, the clock resets for the 4 hours of nothing by mouth

This is not carried on for more than 24 hours; if the child (or adult) can't keep anything down for 24 hours, the doctor really needs to see them. It's effective for those 24 hour bugs with intermittant vomiting. If vomiting is continuous, or combined with constant diarrhea, then dehydration is a much greater concern and the doctor needs to be involved much earlier.

Nowadays, I suppose parents could try substituting fluids with electrolytes available. But we just always found coke or ginger ale more effective (provided it was real coke/ginger ale). My parents still keep coke syrup, which they can get from their local pharmacy, on hand for vomiting.

What family treatments do you use?

Welcome to Mommy Minions

Welcome, and I'm going to start out with an apology. I would like this to be a place where ALL parents, not just mommies, can openly ask questions about parenting, immunizations, whatever. However, I messed up creating the template so that's what the name is for now! And why minions? Tell any parent they are not at a child's beck and call (at least, when really needed).

Parents are welcome to post anything. I will ask that comments be respectful. I'm not against obscene language, necessarily, but don't want this to degenerate into a name-calling sight. While you may believe (and state) that you think someone's ideas are wrong or stupid, you may NOT call that person wrong or stupid.

As we grow, I hope to add links. I will be honest and admit that my HTML skills are very minimal, but we'll see what I can do!