Descripción General del Seguro de Salud

Los seguros de salud constituyen una cobertura importante que ayuda a protegerlo a usted y a su familia de las consecuencias económicas devastadoras que ocasionan los problemas de salud inesperados o una enfermedad catastrófica.

 

La cobertura de salud se puede emitir a particulares, a empleados de un empleador que brinda cobertura de salud o a individuos que son miembros de asociaciones. Algunas coberturas de salud son otorgadas por fondos autoasegurados que no están regulados por el Estado de la Florida. Si bien existen otras formas de seguro de salud, las tres categorías principales de seguro de salud son:

• Policies that provide managed care services, including major medical PPO coverage;

• Policies that offer traditional major medical coverage, and

• Pólizas que otorgan beneficios limitados.

 

Pólizas que Brindan Servicios de Cuidado Administrado

The managed care system combines the delivery and financing of health care services. This limits your choice of doctors and hospitals. In return for this limited choice, you usually pay less for medical care (i.e., doctor visits, prescriptions, surgery and other covered benefits) than you would with traditional health insurance as long as you obtain services from an in-network provider or facility. The managed care network controls health care services.

 

Los Tipos de Cuidados de Salud Administrados son:

• Preferred Provider Organizations (PPOs) - PPOs offer a provider network to meet the health care needs of its insureds. An insurer contracts with a group of health care providers to control the cost of providing benefits to its insureds. These providers charge lower-than-usual fees because they require prompt payment and serve a greater number of patients. Insureds usually choose who will provide their health care, but typically pay a lower deductible and less in coinsurance with a preferred provider than with a non-preferred provider. Most group health policies fall under this category of major medical coverage.

• Health Maintenance Organization (HMO) - HMO members pay a monthly fixed dollar amount (similar to an insurance premium), which gives them access to a wide range of health care services. In many cases, members also pay a predetermined amount, or copayment, for each doctor or emergency room visit and for prescription drugs, rather than paying the provider in full and obtaining a portion of the reimbursement later. Members must use the HMO’s network of providers, which may include the doctors, pharmacies and hospitals under contract with that particular HMO. Emergency services are covered regardless of the network status of the medical provider or facility.

• Point of Service plans (POS) - A Point of Service plan is a HMO plan with an out of network option. In a POS plan, insured members may choose, at the point of service, whether to receive care from a physician within the plan’s network or to go out of the network for services. The POS plan provides less coverage for health care expenses provided outside the network than for expenses incurred within the network. Also, the POS plan will usually require you to pay higher deductibles and coinsurance costs for medical care received out of network.

• Exclusive Provider Organizations (EPOs) -In an EPO arrangement, an insurance company contracts with hospitals or specific providers. Insured members must use the contracted hospitals or providers to receive benefits from these plans. Emergency services are covered regardless of the network status of the medical provider or facility.

 

Policies that provide Traditional Major Medical coverage

Traditional health coverage is provided by major medical policies and is more expensive because it provides more benefits than basic policies. A major medical policy normally pays a percentage of covered expenses (normally 80%), after you pay the deductible. Insurance companies use fee schedules to determine the reasonable and customary cost of a procedure; however, this cost may differ from the actual charge you receive. Maximum out-of-pocket limits restrict the amount of coinsurance you pay. Not all policies include such limits, but those that do pay 100 percent of remaining covered expenses after you pay a stated amount of coinsurance. You are not restricted to a particular network of medical providers under a traditional major medical policy.

 

Pólizas que otorgan beneficios limitados

Aunque existen otras, las pólizas más conocidas que otorgan beneficios limitados son:

• Básica de Gastos Hospitalarios - Hacer clic aquí para obtener mayor información.

• Básica de Gastos Quirúrgicos - Hacer clic aquí para obtener mayor información.

• Enfermedades específicas como el cáncer - Hacer clic aquí para obtener mayor información.

• Planes de Indemnización del Hospital - Hacer clic aquí para obtener mayor información.

 

Existen otros tipos de servicios relacionados con la salud que NO son planes de seguro de salud

Estos son:

• Discount Plans* - Medical Discount Plans, Prescription Discount Plans, Dental Discount Plans, and Vision Discount Plans are programs where a consumer pays a fee to join a plan in return for discounts on products and services from participating vendors and providers. Often, members who join these plans are issued a card similar to an insurance card identifying them as a member. However, these plans are NOT insurance. You are responsible for the provider’s discounted charges at the time of service.

*Advertencia para el Comprador: Hacer clic aquí para obtener una lista de las cosas a considerar antes de comprar un Plan de Descuento Médico.

 

Consejos sobre Seguros de Salud

• ¡¡Verifique antes de comprar!! Contáctenos a fin de verificar la licencia del agente y de la compañía de seguros antes de firmar la solicitud para una póliza.

• Guías para Seguros de Salud The guide is an excellent tool if you are shopping for a specific type of insurance and would like to gain a better understanding of all the aspects of the product prior to making your purchase.

• Lista de Aseguradoras para Grupos Pequeños Una lista de compañías que ofrecen seguros de salud a Propietarios de Pequeñas Empresas de la Florida.

• Lista de Aseguradoras para Personas Particulares Una lista de compañías que comercializan pólizas de seguro de salud con emisión garantizada para individuos elegibles según se define en la Sección 627.6487(3) de los Estatutos de la Florida.

• Review your policy carefully!!!! Understand your deductible and coinsurance provisions. Understand your responsibility if you need a referral to see a specialist. Also, understand your rights to file an appeal or grievance if a claim is denied that you feel should be paid.

• Regulated individual plans have a 10-day free-look provision. This allows you to return the policy and receive a full refund if you are not happy with the policy.

• An individual policy must include a grace period provision. The grace period is from 7 to 31 days, depending on how the premium is paid. Individual HMO’s must provide a 10 day grace period.