Consumer's FAQs
David Gilston Insurance Agency, Inc.

Carrier networks are extremely important for two main reasons: area of coverage and discounts. First, the carriers who have the largest networks provide a greater choice among doctors. Most people want to maintain their relationship with their existing doctor, hospital or pharmacy so verify that provider is in the network.

Second, and even more importantly, are the discounts the providers give to the insurance companies. Lower discounts result in you, the patient, having to pay less out of your pocket for healthcare. Generally speaking, the insurance companies who have developed their own networks tend to receive a greater discount than the companies who rent access to a network. Ask your agent if your insurance company owns or rents its network.

Discount amounts are not always easy to determine before selecting a policy but your agent can share a typical discount range with you. Some companies will show you their particular discounts if you can provide them with an ICD-9 code, which is the code doctors use to classify procedures. Insurance companies will mail an explanation of benefits (EOB) to you for each service you receive using your benefits. The EOB will show you the amount billed by the provider and the allowed amount by the insurance company. The difference is the discount you receive and do not have to pay if you are in-network.

Unfortunately, if you do not reveal a health condition to the insurance company and require treatment for that condition at some point in the future, the insurance company can rescind the policy for misrepresentation, refund your premiums and not pay the claim. Carriers handle pre-existing conditions differently by excluding the condition, rating up for the condition, or declining you entirely. Disclosing all your health conditions will allow the agent to find the best policy for you. Using an agent to guide you through the application and underwriting process can minimize errors.

Price is a hot button for buying health insurance. However, just because one plan is cheaper than another doesn't mean you are comparing apples to apples. Insurance company discounts should play an important role in your decision for selecting a policy, as you will realize these savings when you use your benefits. Also, less expensive policies typically have larger deductibles that you will be responsible for paying. Placing money into a reserve fund, such as a tax-free health savings account, can serve as a cushion for your medical expenses. Speak with an agent to enroll in a health plan that qualifies you for this type of an account.

Carriers will be required to establish an open enrollment period for children under the age of 19, which will allow children to be enrolled in a health plan regardless of any pre-existing health conditions.

You should review all your insurance plans as your personal situation changes, including marital status, dependent status, financial status and occupation. Selecting a plan initially that will allow you flexibility in the future is more advantageous because you may be unable to change carriers if your health changes.

• Are you planning to have a family in the future?
• Where do you reside and how extensive is the network of the particular coverage you want?
• Is coverage available through either your employer or your spouse's employer? Does this coverage meet your current and future needs?
• Are you able to put money into savings to take care of the smaller expenses that may arise?
• Is prescription drug coverage important to you?

Carrier networks are extremely important for two main reasons: area of coverage and discounts. First, the carriers who have the largest networks provide a greater choice among doctors. Most people want to maintain their relationship with their existing doctor, hospital or pharmacy so verify that the provider is in the network. Second, and even more importantly, are the discounts the providers give to the insurance companies. Lower discounts result in you, the patient, having to pay less out of your pocket for health care. Generally speaking, the insurance companies who have developed their own networks tend to receive a greater discount than the companies who rent access to a network. Ask your agent if your insurance company owns or rents their network.

• Do you believe that generic drugs are equally as effective as brand name drugs?
• If you are taking drugs, are they covered under the formulary as a preferred or non-preferred brand name drug?
• Does the plan you are considering buying require you to go through step-therapy, impose quantity limits or require you to take an alternative drug before the carrier will cover a particular drug your doctor prescribes for you?