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The seven characteristics of great coverage are:
- Nationwide network
- Prescription card
- Transplant coverage
- No limits on room and board, including ICU (Intensive care unit)
- Outpatient and inpatient coverage
- Therapy coverage
If your health insurance plan is missing one of these, your coverage is compromised and either you’re going to get limited care or you’re going to end up with a lot of cash out-of-pocket expenses if you get sick or have an injury or both. So, let’s talk about each one:
A Nationwide Network is required and an absolute must. This is especially true if you live close to any state line. With many plans, as soon as you go out of state, you are out of the network and your benefits drop by an average of 20%. They go from 80/20 on the co-pay to 60/40, and the “stop loss” limit of $10,000 goes away; so instead of owing 40% of $10,000, you could owe 40% of the whole bill! If you had a heart attack with one of these policies while traveling out of state, and the hospital and doctors cost $500,000, your co-pay could be $200,000! There are dozens of companies who sell policies with terms like this buried in the fine print, and it’s one of the big secrets that these insurance companies do not want you to know. But don’t worry, because we don’t let our clients participate with any insurance company that doesn’t offer a nationwide network of hospitals.
A PPO (Preferred provider organization) is necessary so that you have a choice of doctors and hospitals and you don’t have to get a referral to go to a specialist. The PPO discount can be huge; as much a 70%. There are six companies that are both a PPO and offer a nationwide network.
A Prescription Card is a must. Today’s prescriptions can run anywhere from a few dollars to $5000 per pill! You might need an expensive prescription to save your life. The purpose of insurance is to pay for this. You should not pay for insurance and then also be stuck with the huge cost of prescriptions.You want to avoid prescription limits of $2000. Even some of the best companies offer this $2000 limit as a choice, but if you have a major illness or accident, you could run up more than $2000 in prescriptions in a hurry.
Transplant Coverage is a critical element. Never enroll in any health insurance plan that does not cover transplants, or that has limited transplant coverage. Nobody ever thinks that they will have a transplant in their lifetime, but if you go to any transplant center in the US you will find people of all ages, from all walks of life, who needed a heart, liver, lung, kidney, and bone marrow transplant. Due to the scarcity of the specialized centers, it is not likely that the transplant center you may need will be in your particular state, which means that you must-have full transplant coverage and you must have a nationwide network.
Room and Board with no limits (including intensive care unit) is essential. The average overnight stay in the hospital today is more than $1000. You do not want a plan that covers $200 per day or $400 per day or $600 per day, leaving you with a huge bill to pay when you get out of the hospital. There are many plans sold every day with these types of limitations, but if you had a seven day hospital stay and your plan only covered $400 dollars per day, you would owe an additional $4200, over and above what your insurance plan would cover. Also, intensive care coverage is typically four times the cost of a regular hospital room, so if you spent those seven days in the ICU, you would owe more than $16,000. That’s why we don’t offer coverage that has limits on room and board.
Inpatient and outpatient coverage is a must in today’s environment. As I said earlier, more than 75% of all medical procedures are now delivered on an outpatient basis, but there are still many hospitals and surgical plans that do not cover one penny of outpatient services. There are other plans that limit outpatient claims to a certain limit. If you have a $500,000 outpatient claim and your outpatient limit is $200,000 you’ll be stuck with $300,000 of non-covered charges. You don’t want a plan that doesn’t give you unlimited outpatient coverage.
Therapy coverage without limits is a must. You must have coverage on occupational, vocational, rehabilitation, radiation, physical and chemotherapy. Many insurance plans will limit the number of visits. For example, if you tear your Achilles tendon, some plans will limit you to five hospital visits, but your recovery time will actually be 6 to 10 weeks and may require as many as 20 visits for therapy. So, your plan must have therapy coverage, without exclusions, and must not be limited to anything less than 25 visits per occurrence.