Medical Expense Issues

• Deductibles: How much of the initial costs must you absorb in the way of a deductible? Is it charged only once in the calendar year? Is there a limit of two or three deductibles per family or must each member satisfy it?
  
  
• Coinsurance: Beyond the deductible, what percentage of the expense must you pay, 20%, 30%? Most important - Is there a "stop-loss" provision which eliminates all coinsurance and pays 100% of the charges after you reach $2,000 or so in out-of-pocket expense?
  
  
• Family benefit maximums should be "unlimited" or extremely high; e.g., $5,000,000 due to potential costs of a major surgery, hospitalization, a series of family illnesses, etc.
  
  
• "Inside limits," like "$200 for X-rays" etc., should be avoided in favor of "comprehensive coverage"; i.e. a flat percentage of the cost incurred.
  
  
• Determine age limits on child coverage. Full-time students may be covered until 22 or 23.
  
  
• Outpatient benefits should be examined carefully since many procedures are now done on an outpatient basis; e.g. pre-admission testing, diagnosis, etc., due to the high costs of hospitalization.
  
  
• Preferred Providers: Some medical plans call for the use of a preferred supplier and provide a list of doctors or hospitals from which you must choose
  
  
• Health Maintenance Organizations (HMOs) offer a different approach from traditional health insurance, in which you pick the doctor, pay as you go and receive reimbursement from an insurance company. With an HMO, you or your employer pay an annual fee, for which the plan's own doctors handle almost all of your health needs.

HMOs typically cost less in that there are usually no deductibles and they cover a higher percentage of costs than traditional plans. However, since you are limited to the services of this organization, it is important to ask: