Coverage—An Overview

While health insurance plans in general contract to pay a sum of money to the insured in the event of a medical claim in return for the payment of premiums, you may find that there are many variations in coverage. Some health plans require patients to pay large deductibles or limit benefits, while others give broader coverage and require little out-of-pocket expense. As a consumer, it's important to understand your insurance. Below you'll find an overview of insurance types:

Group insurance policies—most people are covered by group insurance policies, which are designed to keep premiums lower by sharing expense risks among members of the group.

Public insurance—insurance provided through government programs such as Medicare and Medicaid.

Private insurance—private insurance usually falls into one of three categories:

  • Commercial insurance—commercial insurance companies such as Aetna, Cigna, Oxford, etc.
  • Non-profit insurance—insurance companies such as Blue Cross/Blue Shield
  • Self-insuring groups—groups, such as employers, who pay claims directly rather than employing an outside insurance carrier

Many insurers are using managed care formats to lower the costs and improve the quality of healthcare. Managed care plans contract with healthcare providers and facilities to provide care for members at a lower cost. Typically, more flexible managed care plans (those that allow you to see out-of-network providers) are more expensive, while those with more restrictive rules tend to be more affordable.

Mandates

You may live in one of the 15 states (AK, CA, CT, HI, IL, LA, MD, MA, MT, NJ, NY, OH, RI, TX, WV) that provide mandates for infertility services. Mandated benefits vary by state. An actual mandate requires insurers to provide infertility coverage, but some states only have a "mandate to offer." A mandate to offer requires insurers to offer coverage, which employers may or may not choose to purchase. Mandated coverage may also depend upon the relationship between you and the insurance carrier. Mandates usually target traditional health insurance companies.

Occasionally, mandates also cover managed care plans that are doing business within a given state. However, Federal ERISA (Employee Retirement Income Security Act) laws exempt self-insured groups from state mandates.