Medical health insurance in the American society is an issue that requires continued reforms and improvements. The majority of Americans are confused with the many private insurance plans available that are not standard for ease of understanding (Austin, 2010). Despite the fact that we have the private and government-funded insurance plans, most Americans believe that the private insurance plans take good care of their medicals needs in a much better way than the government plans. With the increasing medical costs and the many ailments that are in the society today, every person requires having insurance that will cater for his or her medical expenses. This paper examines three common insurance plans in the market and looks at their characteristics and benefits. It answers some pertinent questions related to the plan of my choice and why I decided to choose that particular plan, the difficulties I experienced in making my choice and the circumstances that may change my plan. Although medical insurance is a central requirement by all Americans, the different plans that give different names to the same thing is meant to confuse the public and deny them their right to information and knowledge.
Part 1
Part 2
Healthcare insurance in the US is categorized into two groups, the private and government-funded plans. The private health insurance plans include the HMO, PPO, EPO, and POS while the government-funded plans include Medicare and Medicaid (Austin, 2010). These plans have varying benefits, costs, and features that are differentiated by the services derived from the plans. From the chart above, I decided to choose the PPO plan as appropriate for my family and myself.
What are the most important features that imparted my plan choice?
When choosing a medical health insurance plan, what is critical is your ability to pay the monthly premium, your current health condition, the out-of-pocket expenses I will pay for medical care and my preferred metal category that can serve me better. These factors play a key role in the choice of the plan I made.
The monthly premium I will be pay incidentally will be determined by my metal category that I will choose (Smith & Medalia, 2014). Because I am a healthy person with no known medical condition, I do not expect to be visiting the hospital quite often until when I start approaching age 50 when I will need frequent visits to the hospitals for checks. The visits will ensure that I get to undertake preventive care and wellness procedures that will improve my health. From the available metal categories, I prefer to have the silver plan that the insurance pays 70% of the total cost of the treatment, and I pay the remaining 30% with a lower out-of-pocket cost plan. The average deductible for this category is $2907. The monthly premium for this plan is high, but the category is appropriate for someone like me who does not visit hospitals occasionally. I would have chosen the bronze category, but the main disadvantage of that plan is that it has a high out-of-pocket cost averaging about $5081(Smith & Medalia, 2014).
My health condition is good and, therefore, my choice of the silver plan under the PPO plan is appropriate since I do not expect to be visiting the hospitals frequently. My father who is in his mid-50s is also not diagnosed with any known ailment that requires him to be visiting the hospitals frequently. He requires the free preventive and wellness checks and training that are offered by the PPO plan (Smith & Medalia, 2014). My mother similarly is in good health and just like my father she has reached the age of getting preventive and wellness training sessions to straighten and relax the body.
The out-of-pocket cost of the plan is reasonable at $2907 although it is still fairly high compared to what you pay with a gold metal category at $1277(Smith & Medalia, 2014). The problem with anything above the silver metal is that the monthly premiums are unaffordable for my case. If I had a medical condition that would occasionally force me to pay such out-of-pocket costs them, I would have preferred to take the gold or platinum metal category that have low expenses from my pocket.
Lastly, another feature that drove me to choose the PPO plan is its flexibility that you must not have a PCP (Smith & Medalia, 2014). A PCP is very important for someone who has a medical condition because the PCP will be in a condition to clearly understand my ailment and therefore provide better healthcare. Otherwise for a person who does not have a medical condition it is not wise to have a PCP. The plan also provides me the freedom to get treatment in any health facility without the referral of the PCP which in this case it is a good idea although a bit expensive. It is not a major issue for me since I don’t expect to be visiting the hospital frequently but if I was I that state then getting a PCP would be good.
What difficulties did you face in choosing the plan?
Choosing a medical insurance plan is very difficult. Several issues have to be considered and factored in the entire cover otherwise you may find that at the time you have a problem you get surprised when informed that the issue you have is not covered in the plan(Basu, 2013). The difficulty of insurance plans is to understand in details what is covered and what is not. It is very troubling when you are sick, or you have a family member who is sick and requires treatment only to find out that whatever is to be treated is not covered in the policy. Insurance companies need to open up to their clients by ensuring that they provide all the required information to their clients and the available plans so that they can make informed decisions based on their ability to pay the premiums and the cost-sharing of the bills cost. Some members have been unable to pay the out-of-pocket costs because of the lack of enough information on how the system or cover operates (Basu, 2013).
Secondly, it is not easy to choose one cover that will meet the needs of all family members (Basu, 2013). Family members of different ages, health, and status have different needs. My father and mother, for instance, may need a different plan from mine because they currently need a lot of preventive care and wellness programs while my younger sister may require a plan that does not require the wellness program. In a nutshell, it is hard to have a homogenous cover for the entire family without compromising on the needs of some members.
Getting a balance between the out-of-pocket cost and the premium is a challenge. It is difficult to get that balance because it is important in directing which plan to use that depends on you ability to pay the monthly premiums. When I looked at the silver metal category, its premium was higher than those of the bronze metal, but the bronze category had a higher cost-sharing value that I believe paying that every year and not using the health care services is a waste and additional expense. I had to do the balance of paying a higher premium and a lower cost-sharing cost. If I had considered the gold metal category, I would have paid a very high premium although with a low cost-sharing value. That would make meeting my monthly bills difficult (Basu, 2013).
Under what circumstances would your plan choice be different and why?
Health insurance plans will always be confusing and complicated for any ordinary person to comprehend without a clear explanation by the relevant provider (Collins et al., 2015). Several circumstances can change your plan and make it different from what you expected initially. These issues are as a result of lose of coverage due to divorce or separation, loss of a job or reduced working hours, the death of a spouse who maintained my coverage on the policy, the loss of the dependent status, getting married and the birth or adoption of a child. These factors would have to change the choice of my plan.
When a couple gets divorced in a legal process or separates, they cease to stay together, and their dependencies come to an end. Your contribution on the cover policy has to change, and that requires that it must change in terms of the monthly premium paid and the expected annual cost-sharing amount (Collins et al., 2015). Secondly, when I loose my job I become completely unable to contribute my monthly premiums and the out-of-pocket amount that is paid every year may be difficult for me to pay. That changes my policy for lack of a job that would have guaranteed payment of the premium. Similarly, reduced working hours affects my financial capability to meet the premium demands and the cost-sharing amount. That will require that I opt for a plan that has lower premiums that I can sustain for my reduced working hours. Thirdly, if my spouse or I die, the policy will change because one person who was dependent on the plan is no longer available. The premiums will have to change to the lower levels to take effect of the missing person. Fourth, when a member of my family as a brother or sister who was dependent on the cover gets a job and becomes self-reliant that changes the cover that had incorporated him or her as a family member who was a beneficiary of the plan. A reduction in the number of people in the plan reduces the premium which is a relief of my burden. Fifth, when I get married, the plan changes because a new member has joined the family and must be part of the health insurance plan that covers the entire family. That in itself increases the premiums of the cover and the choice of the plan that the family has to subscribe to with increased membership (Collins et al., 2015). It is the same case when I get a child or adopts a child as a new member of the family.
The other issue that may change my plan is when it is found at the time of application that I have a medical condition that I had never known. Before getting an insurance plan approved, it is a requirement that the applicant and dependents are tested and diagnosed with any medical condition. However, if one person is found to have a medical condition that will directly change the plan (Collins et al., 2015). For instance, if it happens that I have been diagnosed with diabetes which requires frequents clinic checks and expensive medications then I will have to negotiate for a plan that can easily accommodate those costs. Some doctors would also use your family medical history to determine the plan you are expected to get because they believe some diseases are genetic and will definitely come up with the family members at one point in their lives.
Conclusion
Medical health insurance in the US is a complex thing that makes most Americans opts for an open enrollment policy. This complication has made medical insurance to be shrouded in secrecy and corruption by the providers of the services (Emanuel & Liebman, 2012). In the current American society, the healthcare insurance sector is the most corrupt section that is depriving Americans millions of dollars for services that they have not received. It is a crisis that the current healthcare reforms are trying to correct with the enactment of the Obamacare. The issue is made more complex because the private providers of the insurance plans do not have a standard plan for the Americans available in all states. Some states have some plans will others don’t have them something that keeps on confusing the clients or users of the service (Emanuel & Liebman, 2012). What is important now is to try to understand what features are in a specific plan as well as the accompanying benefits and costs that determine the premium to be paid.
References
Austin, D. A. (2010). Market Structure of the Health Insurance Industry (Vol. 7, No. 5700). DIANE Publishing.
Basu, R. (2013). The Broken State of American Health Insurance Prior to the Affordable Care Act.
Collins, S. R., Rasmussen, P. W., Doty, M. M., & Beutel, S. (2015). The rise in health care coverage and affordability since health reform took effect. New York: The Commonwealth Fund.
Emanuel, E. J., & Liebman, J. B. (2012). The end of health insurance companies. New York Times Opinionator. January, 30.
Smith, J. C., & Medalia, C. (2014). Health insurance coverage in the United States: 2013. US Department of Commerce, Economics and Statistics Administration, Bureau of the Census.
