Securing coverage: It's nasty out there

WASHINGTON — Health attention coverage is cardinal to a family's fiscal security, perhaps 2nd lone to a paycheck. For the huge bulk of workers, medical insurance come ups through an employer. But more than employers, particularly littler ones, state it is too expensive to supply wellness coverage for workers. As a result, a growth figure of Americans are faced with purchasing insurance for themselves.

The coverage industry reasons that most people who desire policies can acquire them and that they will be adequate. Critics, however, postulate that many people either are rejected for insurance or can't afford it, and that those who make acquire a policy may happen its protections very limited.

Although about 18 million Americans make purchase coverage on their own, nearly 47 million have got no coverage at all. (The remainder are covered through their employers or under a authorities programme such as as Medicare for the aged or Medicaid for the poor.)

At issue is what is called the individual medical coverage market. This is insurance bought one policy at a clip from commercial carriers, and it differs in many of import respects from the grouping marketplace in which employers supply coverage to their workers and, with declining frequency, to retirees.

First, much of the grouping marketplace affects companies, typically large ones, that see themselves. In simplest terms, these employers hold to pay their employees' health-care costs themselves and engage another company,

often an insurer, to administrate the claims. Self-insured health attention programs are regulated by a federal law, the Employee Retirement Income Security Act of 1974.

The individual marketplace is regulated by the states, so demands on insurers, consumer protections and policy offers change widely.

When people go forth grouping plans, parts of two other federal laws may come up into play: the Comprehensive Autobus Budget Reconciliation Act of 1986, and the Health Insurance Portability and Accountability Act of 1996, known by their acronyms, cobra and HIPAA.

Despite all those laws, billions of Americans cannot acquire insurance, either because they can't afford it or because they are rejected by bearers as too ill to insure.

Nonetheless, because a terrible unwellness or hurt can ensue in 100s of one thousands of dollars in medical bills, middle-class and even well-to-do families who make not have got insurance through an employer demand to seek to acquire whatever protection they can.

If you don't have got an employer plan:

The first measure is to get educating yourself about the wellness coverage marketplace in your state. A good topographic point to begin is a Web land site tally by the Georgetown University Health Policy Institute, www.healthinsuranceinfo.net. Chink on your state, and you can acquire summary information on consumer protections and what private insurance companies may and may not do.

Then believe about what sort of coverage you need. In general, experts say, you should concentrate on protecting yourself against catastrophic medical disbursals and concern less about having your routine disbursals paid.

"It's break to purchase comprehensive benefits with a high deductible as opposing to first-dollar (coverage) with limited benefits," said Karenic Pollitz, research professor at Georgetown's Health Policy Institute.

You should also look for a policy that is renewable at your option. Many people, especially immature grownups expecting to take a occupation soon, purchase impermanent policies for, say, six months, figuring that's all the insurance they'll need. But this a risk.

"The job with impermanent policies is that they are temporary," Pollitz said. "If you acquire a job, fine, but if you don't, you are forced to renew. If you've had no claims, you can renew. But it's a six-month policy, and if you acquire ache after four months, it pays the measures for two months. Then it's not renewed . . . "

You should also look carefully at internal caps and bounds the policy may have. What is the lifespan upper limit the policy will pay? "Ideally there should be no limit, but $2 million should be the absolute stone underside to accept," said Nancy Metcalf of Consumers Union. "Anything less and you're really putting yourself at risk."

But then there is the inquiry of the premium. To acquire a sense of the scope for person in your state of affairs and your state, the Web land site eHealthInsurance.com offerings a scope of terms quotations, and you can acquire inside information on policies.

You may desire to see an "HSA-compatible" policy, which have high deductibles but lets you to set aside an equal amount in a tax-deductible, health-savings account that is tax-free if used for medical expenses. Such programs work best if you are healthy — no chronic ailments, for illustration — and in good adequate fiscal form to fund the HSA account.

In addition, Consumers Union's Web land site includes a worksheet for policy comparisons. That one's at consumersunion.org; chink on "health care" at the bottom, then on "health insurance," then "individual policies," and finally on "Consumer Reports: Plan cost and insurance worksheet."

Finally, if you happen a policy that expressions good, will the insurance company sell it to you? In most states, that's up to the insurer. "The medically underwritten marketplace can be very hard to enter," said Pollitz.

Different bearers have got different rules, of course, so shopping around may acquire you over this hurdle. But perhaps not. If you're refused coverage, inquire your state coverage regulator if there are companies offering "guaranteed-issue" policies for which you can't be turned down. Such policies be given to be very expensive.

There are really only two surefire solutions in today's individual market, said Metcalf: "Be healthy or be rich."

If you have got got an employer's program but are leaving the company:

People leaving a workplace group-insurance program have some options that others in the individual marketplace make not. First, under the Comprehensive Autobus Budget Reconciliation Act of 1986, which uses to workers at companies with 20 or more than employees, you have got the right to go on on your employer's program for up to 18 months, and in some lawsuits longer. This agency you can maintain the insurance you had and don't necessitate to worry about being turned down because of unwellness or a "pre-existing condition."

The enlistment is that you no longer pay just the employee share that you probably had to cover when you were on the job. Now you'll have got to pay the full insurance premium and perhaps a 2 percentage administrative fee allowed by the law. The amount can exceed $1,000 a calendar month for a family, based on the norm cost to employers of nearly $12,000 per employee for wellness coverage last year. It's not surprising that lone about 20 percentage of workers eligible for cobra insurance take it.

However, if you had a good program at work, experts said, it's likely to be better than anything you can acquire in the individual market. Sign up "if you can possibly swing it, especially if you have got a pre-existing condition," said Nancy Metcalf of Consumers Union. Not only make you acquire the coverage you are used to, but it also "preserves your right to purchase insurance" in the individual marketplace when your cobra benefit runs out, she said.

Continuing with cobra do you "HIPAA-eligible" when you come in the individual market. The Health Insurance Portability and Accountability Act of 1996 necessitates states to have got at least two policies available without pre-existing condition exclusions.

If a state doesn't have got those two policies available, then it must put up an assigned hazard pool, which is an agreement under which insurance companies in the state share the insurance for people not able to purchase a policy on the unfastened market. However, HIPAA doesn't modulate what the bearers of the policies can charge, though some states do.

Finally, when considering cobra and HIPAA, retrieve deadlines. You have got a right under the law to cobra benefits, but you lose that right if you neglect to exert it within 60 years of the expiration of your grouping coverage. You have got 63 years from the termination of cobra insurance to use for HIPAA-eligible coverage.