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health insurance for individuals
To find out about each state's specific requirements regarding individual health insurance policies, please see NAHU's Health Care Coverage Options Database. The database also contains contact information for the state regulators of individual health insurance policies to use if you have questions or concerns.
If you belong to an HMO, typically you must receive your medical care through the plan. Generally, you will select a primary care physician who coordinates your care. Primary care physicians may be family practice doctors, internists, pediatricians, or other types of doctors. The primary care physician is responsible for referring you to specialists when needed. While most of these specialists will be "participating providers" in the HMO, there are circumstances in which patients enrolled in an HMO may be referred to providers outside the HMO network and still receive coverage.
This is generally referred to as a stated maximum benefit. The lifetime maximum limits on health insurance might range from $100,000 to $1,000,000. Some policies can even have unlimited benefits. Just as the maximum benefit can vary, so can the amount of the stop-loss limit depending upon the insurer.
Co-payment: Another way of sharing medical costs. You pay a flat fee every time you receive a medical service (for example, $5 for every visit to the doctor). The insurance company pays the rest.
Self-insurance is a situation where an employer provides health benefits to its employees by depositing money in a special self insured fund which pays for reimbursement of medical expenses from the fund. This is not a viable option for most employers which must be large enough to have a base from which to predict expected expenses.
Another possibility is obtaining coverage through an association. Many trade and professional associations offer their members health coverage—often HMOs—as well as basic hospital-surgical policies and disability and long-term care insurance. If you are self-employed, you may find association membership an attractive route.
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