By Michelle Phipps-Evans
The District of Columbia Department of Insurance, Securities and Banking (DISB) recently declared November as the District’s second annual Health Insurance Awareness Month. This declaration was aimed at raising awareness about health insurance possibilities and encouraging families to review their health insurance needs. The intention was to focus on the number of District of Columbia residents without health insurance, and to make health insurance information understandable and more accessible to the public.
“Health insurance is a significant expenditure for most DC residents, and recently the health coverage options offered by companies have become increasingly more complex and expensive,” said DISB Commissioner Thomas E. Hampton. “It is especially troubling that more than ten percent of District residents are without any health insurance coverage at all; therefore it becomes essential for us to continually inform residents about the types of private and government-sponsored health insurance plans and types of coverage available to them.”
On November 7, DISB launched its Facebook page. The social networking website that targets younger residents now has 15 fans of the page so far. During the month, the agency added weekly notes on choosing the best options for your family, using the open enrollment period for Medicare Part D to review your coverage and answers to health-insurance-frequently-asked questions. Commissioner Hampton hopes that by using this communication tool to bring attention to health insurance, the agency will be able to give this audience the right message about the importance of having health insurance coverage that meet their specific needs. At times, younger people feel they are invincible and they sometimes falsely believe they do not need or cannot afford health insurance.
DC Mayor Adrian M. Fenty issued a proclamation to recognize the city’s ongoing efforts to close the gap of uninsured citizens in the District of Columbia. Last year, DISB developed the healthinsurance.dc.gov website in partnership with the Department of Health and the Office of the Chief Technology Officer. It offers comprehensive information on health coverage options both in the market and through government-sponsored programs, as well as demographic-specific information on insurance options for individuals, families and small businesses. DISB encourages Web surfers to visit the page often.
What Health Insurance Plan Options Are On The Market?
Major Medical Plans
These types of health insurance plans typically cover a comprehensive array of health care needs, primarily in cases of serious injury or illness, including doctors’ visits, drugs and hospital care. Such coverage may be delivered through a variety of possibilities:
- Indemnity plans—This type of health insurance plan usually has a pre-set deductible and delivers the highest degree of flexibility concerning the place you will receive care.
- Preferred Provider Organization (PPO) plans—With this type of health insurance plan, the insurance company enters into contracts with certain health care facilities and specialists in order to get a discount for their services. Having a PPO health insurance plan, you will face higher insurance rates in case you choose to receive care from a facility or a doctor, which is not part of the PPO list with your insurer.
- Health Maintenance Organization (HMO) plans—In case of an HMO plan you are required to choose your primary care physician (PCP) from a predetermined list of health care providers. To have your claim reimbursed through the HMO plan you have to receive a referral from your PCP for services rendered by any network specialist. In case you address a health care provider outside the network, you will not be covered to the full extent or at all by the insurer.
- Point of Service (POS) plans—This type of health insurance plan is essentially a cross-over between HMO and PPO plans. It provides a higher degree of flexibility compared to HMO plans, although still require a PCP to be chosen. The element of a PPO is that you can address your issue to any facility out of the network for a higher cost.
Limited Benefit Plans
Limited health insurance plans are aimed at providing coverage in pre-set cases of certain conditions, injuries or illnesses. Here are some of the options that may be available to you:
- Basic Hospital Expense Coverage—provides coverage of continuous in-hospital services for a period of usually not less than 31 days as well as some other services.
- Basic Medical-Surgical Expense Coverage—provides coverage of costs for a necessary surgical intrusion as well as for a period of hospital care.
- Hospital Confinement Indemnity Coverage—a type of coverage that pays a certain amount of money for each day spent at the hospital. This is not the percentage of the actual care costs.
- Accident Only Coverage—provides insurance coverage in case of accidental injury, disability, dismemberment or death. There’s an option of covering only certain types of accidents.
- Specified Disease Coverage—health insurance coverage provided in case the policy holder is diagnosed and treated against a specific disease or range of diseases.
- Other Limited Coverage—this type covers only specific health care services, such as vision or dental care.
Risk-Sharing and Discount Plans
Discount plans and risk-sharing plans are different from health insurance plans. Before signing the contract, make sure you are fully aware of the benefits this program will bring and the ways it actually works.
- Discount Plans—You may receive advertisements of cheap health care services in return for a monthly fee. These are not health insurance plans. Don’t confuse them with licensed plans because their participants don’t have the same insurance coverage or protections under licensed health insurance. DISB strongly recommends that you perform an in-depth investigation of any discount plan that promises considerable reductions in health care costs.
- Non-Licensed Risk-Sharing Plans—There may be offers from groups of individuals, who will request a monthly fee that will be placed into a trust or a savings account, which is used to cover the health care costs of all the participants. Do not confuse such offers with licensed insurance plans, because they don't provide the necessary coverage or protections available to those who buy licensed insurance plans. It is also recommended that you study such plans with much attention.
Important Protection Options for Consumers
- COBRA Continuation Coverage—The federal Consolidated Omnibus Budget Reconciliation Act (COBRA) imposes the employer, who has more than 20 employees, to continue the insurance coverage of an employee, leaving the job. Smaller employers may also be imposed to continue the coverage by the District. The federal Department of Labor, Office of Employee Benefits Security Administration’s website, dol.gov/ebsa will provide the necessary information on COBRA continuation of group health insurance plans.
- HIPAA–The Health Insurance Portability and Accountability Act of 1996 regulates the insurance company’s ability to delay or deny claims, protects the consumer from the possibility of losing existing insurance coverage, allows switching between different health insurance plans in a less risky manner, and prevents cases of insurance discrimination due to health conditions. To learn more about HIPAA visit the Centers for Medicare and Medicaid Services’ website at cms.hhs.gov.
Additional Recommendations on Buying Health Insurance
- Make sure you trust the agent or the insurance company you want to sign the plan with. It would be wise to call DISB, if you are a District of Columbia resident, to verify whether the company or agent is licensed to practice in the District of Columbia.
- Different health insurance plans provide coverage of health care needs, so it is better for you to evaluate all the possibilities. Ask questions, learn more about health insurance plans and consider all options available.
- Before signing the application, be sure to read carefully through all the clauses and be confident about every aspect. Don’t hesitate to ask additional questions and make sure that you’re signing an actual insurance service application and it is stated so throughout the document.
- Check to see if your employer offers a flexible spending account. These plans, which allow you to set aside pretax dollars for medical expenses and child care, are a good way to reduce your out-of-pocket medical costs.
- Finally, consider combining a high-deductible catastrophic plan with a health savings account (HSA). An HSA is a tax-sheltered savings account similar to an IRA, but earmarked for medical expenses. Deposits are 100 percent tax-deductible for the self-employed and can be easily withdrawn by check or debit card to pay routine medical bills with tax-free dollars. Larger medical expenses are covered by a low-cost, high-deductible health insurance policy. What is not used from the account each year stays in the account and continues to grow interest on a tax-favored basis to supplement retirement, just like an IRA. Employers are beginning to offer HSAs to their employees as a health insurance option.
State Consumer Protections
The consumers who purchase health insurance policies are provided with certain health benefits by the District of Columbia state legislation. Some of them are:
- Coverage of specific treatments and services;
- Access to certain specialists and health care providers;
- Prompt payment of claims;
- The appeal of coverage decisions to an impartial external reviewer;
- The appeal of coverage decisions within the insurance company.
If you have questions about protections in the District of Columbia, contact the DC Department of Insurance, Securities and Banking (DISB) at (202) 727-8000.
Michelle Phipps-Evans is the supervisory public affairs specialist in DISB’s Office of Communications.