Have you considered managed care versus integrated care? What is the difference? Do I have what I need? When it comes to choosing the best Medicare plans for yourself or a loved one HMOs (Health Maintenance Organization) are often a viable choice due to affordability, predictability, and financial safety. All HMOs operate based on the concept of managed care but not all have integrated care. It is important to be aware of the difference.
Lets start with managed care. This is when health insurance organizations contract with select providers, pharmacies, and hospitals in their service area to create a network that allows for better control of costs. As a result of this arrangement, members agree to seek non-emergency/non-urgent care with network providers in exchange for lower costs of care.
The primary advantage of the managed care aspect associated with HMOs is the focus on the cost of care which benefits the member and the health plan. Integrated care, however, is when the health plan and providers work together, in close coordination and collaboration, they have a shared focus on the patient experience, quality of care in and cost of care. The additional focus on patient experience and quality of care is often associated with ease of access or robust IT tools resulting in easier communication across the care continuum. STAR ratings are solid indicators regarding performance for quality of care for health plans. When it comes to IT, you'll want to ask what electronic communications options exist with the health plan you are considering. If available, they may allow for better communication to patients and providers, as well as between providers. There is so much more to learn about with respect to integrated care be sure to ask your potential health plan what tools or resources are available that promote integrated care. Some health plans with impress and overwhelm you and some may not be able to give you a straight answer.
Think of it this way: all integrated care HMOs have managed care, but not all managed care HMOs have integrated care. Be sure to ask the right questions so you can make the right decision.
Editors Note: This article was submitted by Matt Engstrom, MBA. Matt is a Medicare Sales Manager at Kaiser Permanente and may be reached at 303-338-3353
Health insurance jargon can be the hardest to understand for consumers. Thats why you have a broker who goes to work for you and explains your policy options with clarity. However, not all brokers work ethically. You may not have an insurance broker who values you and may not elaborate on your policy limitations. The omission of these limits is illegal and should result in the termination of that broker. In contrast, the insured typically doesnt take legal action, and the broker makes his or her desired commission.This is not to say that all health insurance brokers operate in this zone of immorality. Just as with any profession, there are good and rotten eggs. Your moral compass and ability to judge a persons intention is a significant factor people can typically smell a sleazy salesperson. Below, are the most common limitations obscurely mentioned in health insurance policies. This information should adequately equip you for when you are asking questions of your broker.Heres a screenshot from the summary of the benefits of an insurance carriers product:*Note these limitations do not exist in all policies. Ask your broker.The list of benefits above is towards the end of the policy summary. Most people are interested in seven factors when it comes to their health insurance:Deductible/coinsurance/max out of pocket, doctor visits/specialists/urgent care, the network, prescription coverage, preventative/wellness coverage, emergency room fees, and ambulatory services. If your insurance broker goes over those seven things, this is how the policy would look and sound:Choice of $500-$10,000 deductible/max out of pocket (1 million in coverage)Choice of 70/30, 80/20, or 100/0 coinsuranceUnlimited $25 copay to doctor, specialist, and urgent carePHCS Network (PPO)$50 copay for annual wellness/preventative checkupER subject to deductible and coinsuranceAmbulatory services (above) $500 per transportMost people would agree that those seven things sound fantastic for health coverage. You have all your daily doctor needs taken care of and one million dollars in coverage, right? Wrong, let me show you a scary breakdown if you had an appendectomy while being covered by this policy.On average, the Fair Price for an Appendectomy lies somewhere between $7,000 and $25,000 (may vary due to zip code). If there are complications, it could be upwards of $35,000 or more. Heres a breakdown of the services and their estimated costs. You can always check on any surgery, and its price by visiting Healthcare Bluebook.Hospital Services for a 2-day admission, itll cost roughly $9,700.Physician Services the fee for procedure and routine postoperative care costs around $1,400.Anesthesia the price for an average surgery time of 1 hour and 15 minutes costs about $750.This cost adds up to the lower end of about $11,000 for an appendectomy. If you look above at the example policy, youll see that for the entire coverage term an appendectomy will be given a $2,500 coverage benefit. Even though your plan has a deductible, coinsurance, and max out of pocket; theres a specific limitation for appendicitis. With this knowledge, the insured will be left an $8,500 bill as an out of pocket expense! Keep in mind; these numbers are on the low end with no complications.Of course, its always better to have health insurance instead of going uninsured. With insurance, that remaining $8,500 for the appendectomy may negotiate to a lower bill. Policygenius.com does a great job explaining the functionality of network negotiated rates. Without insurance, you would be paying the almost full retail price for your medical surgery, which is a terrifying thought!
You can, but should you?Theres a dark stain over the insurance industry for consumers searching for quotes online. Families and individuals are aware they need to carry health and life protection but dread entering their information online, consequently experiencing the bombardment of phone calls that follow. Its so bad some people would instead go without coverage than speak with a broker over the phone. When in reality, all it takes is working smarter, not harder.Some people will advise you to buy your own auto, home, health, life, or any other insurance. They will tell you horror stories about the number of calls youll receive if you submit information online. They will present a convincing argument, and youll be tempted to accept their advice. I urge you to resist that temptation.Its no surprise that many people are turning to self quoting websites and applications. The appeal is undeniable. Theres nothing inherently wrong about this approach, and it does save the consumer the headache of having to speak to countless agents. However, should you buy insurance without speaking to a licensed broker? Its fine to quote yourself and see whats out there in terms of options, but then proceeding to purchase that insurance without educational guidance is extremely risky for the consumer. When you use past experiences, personal knowledge, and stories heard from friends to make an informed decision on your insurance; the result tends to be medical debt or bankruptcy.A licensed agent or broker has a fiduciary responsibility to you. They are mandated by state and federal law to undergo licensed certification. While you may not have had pleasant experiences in the past, having a broker perform a needs analysis to personalize the policy is a better alternative. Just like any other profession, some paid attention during class, and others did not. It isnt appropriate to blanket statement all insurance brokers as untrustworthy.Heres your solution to avoid entering your information online. Instead, reach out to family members and friends. Ask them whom they use for their insurance needs and their experience with their broker. If you cant find a family or friend who uses a local agent or broker; reach out to colleagues and people within your circle of influence for guidance. By doing so, you are acquiring a real person who is aware of your personal needs and whom others trust. Its an ideal win-win situation between a trusted broker and client. You leave feeling confident in your policy because you are informed, and youve supported a local small business owner and their family. It may not be the fastest solution, but should it?When the world is more efficient, were all happy. Quicker load times, faster test results, high-speed internet. The need for convenience and expedience permeates everything we do. Theres relief in knowing you can quote and compare prices without receiving dozens of calls.However, when you go to purchase your insurance slow down, consult a professional, ask questions, and then fill out your application with the knowledge youre protected and supported.
Navigating Medicare: A Comprehensive Information Guide with MediConnectAre you turning 65 soon or approaching eligibility for Medicare? Understanding your healthcare options is crucial for ensuring you receive the coverage you need. With Medicare being a cornerstone of healthcare for millions of Americans, its essential to familiarize yourself with its information. At MediConnect, our Medicare advisory firm, were here to help you find the plan that works best for you.What is Medicare?Medicare is a federal health insurance program primarily designed for people who are 65 or older. However, it also covers certain younger individuals with disabilities and those with end-stage renal disease. It consists of different parts, each providing coverage for specific services:1. Medicare Part A: Hospital insurance that covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.2. Medicare Part B: Medical insurance that covers outpatient care, doctor visits, preventive services, and some home health care.3. Medicare Part C (Medicare Advantage): A private insurance alternative to Original Medicare (Part A and Part B), often including prescription drug coverage and additional benefits like vision, dental, and wellness programs.4. Medicare Part D: Prescription drug coverage available through private insurance companies approved by Medicare.Understanding EnrollmentEnrolling in Medicare can be a straightforward process if you understand the information for your options and the timing of key decisions: Initial Enrollment Period (IEP): Typically, this is a seven-month period that begins three months before the month you turn 65, includes the month you turn 65, and ends three months after the month you turn 65. General Enrollment Period (GEP): If you missed your Initial Enrollment Period, you can enroll during the General Enrollment Period, which runs from January 1 to March 31 each year. However, late enrollment may result in penalties. Special Enrollment Period (SEP): Some individuals may qualify for a Special Enrollment Period due to specific life events, such as moving, losing employer coverage, or qualifying for additional assistance programs.Making Informed Choices with MediConnectChoosing the right Medicare coverage depends on various factors, including your healthcare needs, budget, and preferences. At MediConnect, our Medicare advisory firm, we take the information you give us to offer personalized guidance and expertise. Helping you make informed decisions: Coverage Needs: Our team will work with you to assess your healthcare needs, including prescription medications, doctor visits, and any specialized care requirements. Costs: Well help you understand the premiums, deductibles, copayments, and coinsurance associated with each Medicare option to determine the total cost of coverage. Provider Networks: Well explain the differences between Original Medicare and Medicare Advantage plans, helping you choose the option that aligns with your provider preferences. Prescription Drug Coverage: Our experts will evaluate your prescription drug needs and compare Part D plans to find the one that best covers your medications at the lowest cost.Additional ResourcesNavigating the complexities of Medicare may seem daunting, but youre not alone. Here are some resources to give you additional information along the way: Medicare.gov: The official Medicare website offers comprehensive information, including plan comparisons, enrollment guidance, and eligibility criteria. State Health Insurance Assistance Programs (SHIPs): These programs provide free, personalized Medicare counseling and assistance to help you understand your options and make informed decisions. Medicare Plan Finder: Use this tool on Medicare.gov to compare Medicare Advantage plans, Part D prescription drug plans, and Medicare Supplement Insurance (Medigap) policies available in your area.As you approach Medicare eligibility, remember that MediConnect is here to support you every step of the way. Our Medicare advisory firm is dedicated to helping you find the coverage that meets your unique needs and preferences.By understanding the various parts of Medicare, enrollment periods, and factors to consider when choosing a plan, you can make confident decisions about your healthcare coverage. Let us guide you through the process and ensure you have the peace of mind that comes with comprehensive Medicare coverage tailored to your individual requirements.