Facts to Know

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1. Health insurance can help protect you and your family from the costs of illness or injury.

2. If you are self-employed or don't work for a company that offers health insurance, you'll have to get it on your own. Individual medical policies are sometimes more difficult to qualify for, more expensive, and have more restrictions on coverage than group health insurance. You might be able to get coverage through a business, professional, or fraternal organization or club. However, make sure you investigate these plans carefully to insure their solvency. Otherwise, you can contact your state's insurance department for a list of health insurance providers in your area. You can also ask the insurance agent who sold you your home, auto, or life insurance or look in the Yellow Pages for independent agents advertising health insurance. However, beware of associations that offer health plans; in recent years, there have been quite a lot of problems.

3. There are three main types of health insurance-indemnity plans, health maintenance organizations and preferred provider organizations-and sometimes employers offer one plan of each type from which you can choose. Your choice will depend on your healthcare needs and your pocketbook. Remember, lower premiums doesn't necessarily mean less expensive in the long run if services you need aren't covered.

4. Fee-for-service plans require you to pay monthly premiums, an annual deductible, and coinsurance, which is usually a percentage-often 20 percent-of your healthcare bills. You can usually go to any health care professional or hospital you want (as long as the type of services provided are covered).

5. Health maintenance organizations or HMOs require you to pay monthly premiums and a co-payment every time you see a health care professional or go to the hospital. You must choose from a list of health care professionals and hospitals. And, in many cases, you must see your primary care physician for referrals to specialists.

6. Under a point-of-service or POS plan, if your primary care physician refers you to-or you decide on your own to see-a health care professional outside of the plan, the HMO still pays all or most of the bill, although you will pay more than if you saw a plan physician.

7. Preferred provider organizations or PPOs require you to pay monthly premiums and a co-payment every time you see a health care professional or go to the hospital.

8. In most HMOs and PPOs, the physician accepts the plan payment as payment in full, except for your copayment. Some insurance plans may only pay for their percentage of a "usual and customary fee" and set these fees themselves. For example, an insurance company may set the fee for a gynecological exam at $60. If your health care professional charges $75 (and refuses to reduce his or her fees), you will be responsible for paying the additional $15, money out of your pocket that won't count toward your co-payment, coinsurance, deductible, or cap.

9. A law called COBRA allows you to keep your group health insurance for up to 18 months after leaving an employer. If you are retiring, staying home with children, changing jobs, or becoming self-employed, you should consider how you'll be insured; often taking advantage of COBRA is your best bet.

10. As part of the Health Insurance Portability and Accountability Act (HIPAA), all insurance carriers cannot cancel coverage unless: you don't pay your premiums, make late payments, commit fraud or lie to the issuer; your issuer is no longer offering your particular type of coverage; you have coverage with a managed care organization (such as a health maintenance organization) and move outside of the service area; you qualify for coverage as a member of an association and your membership to the association ends

11. You should take the quality of a health plan into consideration before purchasing it. Some national and local organizations provide ratings of customer satisfaction, how long it takes to get an appointment, accreditation status, physician qualifications, preventive care, member attrition (the rate of members that leave the plan each year).

12. The federal government passed the first-ever federal privacy standards to protect patients' medical records and other health information provided to health plans, health care professionals, hospitals and other health care providers.