FAQs - About - Plan For Your Health

Frequently Asked Questions

Q1: What is Plan for Your Health?

A1: Plan for Your Health is a public education campaign that gives women important information they need to make health benefits and financial decisions at key moments in their lives — times such as starting a new job, getting married, having a baby or starting over. Because the trend in health insurance is moving toward consumer choice, consumers will have the opportunity to take responsibility for their health insurance/benefits choices. Our campaign seeks to provide them with the tools and information needed to guide their choices.

To that end, Plan for Your Health provides consumers with easy-to-understand and accessible information and resources. These include:

An interactive website with information and tips about different insurance products
Tools to assess how life changes will impact health care plans and finances, including the Health Expense Calculator (a tool to help you estimate your annual medical, dental, vision and prescription expenses based upon your age, conditions and frequency of doctor's office visits) and Your Health Benefits Priorities (an assessment tool to evaluate a health benefits package or compare one or more packages by gauging what you really need from your health benefits plan and the aspects of a plan that are most important to you)

Q2: Why is the campaign focused on health insurance and financial planning?

A2: Many women are confused by their health benefits choices and do not have the information to make the best health and financial choices at key moments in their lives. In addition, many women do not consider their health care decisions as part of their overall financial planning, even though these choices can greatly impact their health and financial well-being. Plan for Your Health gives women the tools to take charge of their health insurance planning at key life events and the resources to make the right individual health and financial choices.

Q3: What organizations are playing a role in Plan for Your Health?

A3: Aetna partnered with the Financial Planning Association to bring this program to consumers.

Q4: What does the average American woman know about consumer-directed health care plans?

A4: Based on a recent survey conducted by Plan for Your Health to evaluate the knowledge of women (the primary health care decision makers) when it comes to health care planning, we found that:

Although most women (65 percent) consider themselves knowledgeable about their health insurance plan, a significant number do not know even basic information regarding the financial aspects of health coverage:
- Fifty percent of women with an employer-sponsored health plan do not know how much the employer contributes to the plan each month.
- A significant percentage of women surveyed (33 percent) admit they do not know what coinsurance is.
- Forty-three percent of women believe a visit to the primary care physician costs less than $50, when in fact, the average office visit costs $200.
Only 19 percent of women have a budgeted amount of money set aside for annual health care costs.

Q5: What are some of the key findings from the Plan for Your Health survey?

A5: This survey revealed that more than half of the women surveyed say they face a challenge in selecting their health insurance plan. When asked about the biggest challenge in selecting a health insurance plan, the most common response was that the information that is available is confusing or hard to understand.

Q6: What should consumers focus on when it comes to health care planning?

A6: In general, consumers should be more aware of how their health benefits and health care choices impact their health and financial well-being. From the Plan for Your Health survey, we found that consumers need to focus on incorporating health care choices into their financial planning. Although 91 percent of women consider their health plan important in ensuring their future financial well-being, only 31 percent consider their health insurance to be part of their financial portfolio.

Q7: How can people learn more about Plan for Your Health?

A7: People can easily learn more about Plan for Your Health by visiting the program's website, www.PlanforYourHealth.com. The site provides information on planning for your health care financial future and tools to help people determine what plan is best for them based on their life event.

Q8: What are some of the features/tools that you offer consumers?

A8: PlanforYourHealth.com has a number of consumer-friendly tools available to help people make the right health insurance and financial decisions. For example, we have a Health Expense Calculator that enables you to estimate your annual medical, dental, vision and prescription expenses based upon your age, conditions and frequency of doctor's office visits. In addition, we offer a Your Health Benefits Priorities personal assessment tool to help you gauge what you really need from your health benefits plan and the aspects of a plan that are most important to you.

Q9: What is a consumer-directed health plan?

A9: Also referred to as "consumer-driven," or "consumer choice," this type of health plan gives members more choice and flexibility in making health benefits decisions and more control over their health benefits dollars. These plans often include a health fund or account for covered medical expenses. Depending on the type of fund or account, unused dollars may be rolled over annually to cover medical expenses in subsequent years for the duration of the members' enrollment in the plan.

Q10: What is the difference between traditional health insurance and managed care?

A10: With traditional (indemnity) insurance, you can select any doctor or hospital at the time service is needed. You do not need a referral to see a doctor. Under managed care, doctors, hospitals and other health care professionals contract with the health plan to form networks that deliver health care services. Normally, you select doctors and hospitals from within those networks to get the maximum coverage available through the health plan. Managed care plans offer consumers comprehensive health services and provide financial incentives for patients to use in network doctors and hospitals. You must also usually receive approval from your plan before you can be admitted to the hospital or see a specialist. Some managed care plans, such as health maintenance organizations (HMOs) and select point-of-service (POS) plans, require you to choose a primary care physician. In an HMO, the primary care physician coordinates your care and refers you to specialists. In POS, the primary care physician has the same function, but you have the option to go directly to a specialist at a lower benefits level. POS plans generally offer more flexibility than HMOs, but premiums are likely to be somewhat higher.

The Role of the Primary Care Physician: Managed care plans reestablish the role of "family doctor" by encouraging a steady relationship between you and your primary care physician (usually a family practitioner, internist or pediatrician). In addition to knowing and caring about you, today's primary care physician coordinates any specialty care and services you might need. He or she manages the medical resources available by guiding you through tests and treatments. If you need a specialist, he or she refers you to one as appropriate.
Billing and Payments: With traditional health insurance, doctors and hospitals bill you or your health plan provider for each service performed. You usually pay a deductible and percentage of the doctor's fees. You are responsible for additional charges if the health plan does not pay the full charges.

Under a managed care plan, network doctors and hospitals generally bill the plan for covered services. Non-network doctors and hospitals bill you directly. You usually pay a co-pay (flat fee) or a co-insurance (percentage of service fee) for services within the health plan's network. If you use doctors, hospitals or services outside of the network, you may have to pay a deductible and a percentage of the charges or you may receive no coverage at all, depending upon the type of managed care plan you have.

Q11: Where can I get a summary of my benefits?

A11: Most employers distribute a benefits booklet directly to their employees. For more comprehensive information, ask for your Certificate of Coverage.

Q12: What is the difference between deductibles and co-payments?

A12: A calendar year deductible is the amount of covered medical expenses an individual pays each calendar year before benefits are paid by the plan. A co-payment is the fee charged by a health care professional to an individual for a covered medical expense or for covered prescription drug expenses.

Q13: What happens to my coverage if I quit my job or I'm laid off or fired?

A13: Under most company plans, you have the option to purchase continued coverage under COBRA under certain conditions.

Q14: What happens to my coverage if I move out of the area?

A14: It may depend on the plan selected by your employer. In many instances you can keep your existing benefits. However, if your plan does not service your new location, you have to choose another plan.

Q15: What if my spouse and I divorce?

A15: The employee/employer needs to submit a termination request if a spouse is no longer going to be covered under the plan. Usually an ex-spouse can elect to continue coverage in the spouse's plan for a period of time under COBRA. Payment for this continuation of health benefits or alternative coverage may be determined by the terms of a divorce. A spouse can be covered (usually on COBRA or an individual policy) if coverage is mandated by divorce decree. This varies by state.

Q16: How do I file a health insurance claim?

A16: People file insurance claims as a request for payment due under the terms of the policy. After a claim is filed, the insurance company will evaluate all of the information to determine if it is their responsibility to pay.

Carefully read the summary description of your plan, which you can get from your plan administrator. From this document, you can find out how your plan works, what benefits it provides and how they may be obtained.
Determine the specific procedure for filing a claim from the plan summary or from your benefits administrator, and follow the instructions carefully to file your claim. If you have questions, contact your plan administrator.
All plans have standards you must meet to qualify for benefits. Determine what these qualifications are, and create a checklist to make sure you have fulfilled them all.
Within 90 days after you file the claim, you will find out whether or not your claim has been approved.

Q17: How do I file a grievance or appeal?

A17:

Reread your plan summary to make sure you weren't denied payment because of ineligibility.
Find out from your plan administrator how to submit your denied claim for a "full and fair review." You have at least 60 days to do this. Be sure to include all relevant information, especially any new information or evidence. Double-check the contact information, including to whom and where the claim needs to be sent.
Within 60 days, you will receive a response with the details of the decision, and the plan rules upon which the decision were based.
If your appeal was denied and you believe the decision was unfair, you can seek legal assistance.

Q18: What type of health insurance do I need if I have a chronic disease?

A18: If you have a chronic disease, you need special health care attention, which means you should take extra care in picking your health insurance plan. You'll use more health care services, and use them more frequently than those consumers without a chronic disease, so you'll want to make sure your insurance plan is the right fit for you.

Look for a plan that has a comprehensive disease management program. Disease management programs provide a team approach to treating, monitoring and coordinating the specialized care you need.
An insurance plan that takes the initiative in programs for patient self-care and early identification and treatment of complications will preserve your health and probably save you money in the long run.

If you need to purchase individual health coverage, your insurer may provide full coverage but at a higher premium. They may also modify the benefits to increase the deductible, or exclude the specific medical condition from coverage. It is important to note that there are federal and state laws about what an insurer is permitted to exclude from coverage.

Q19: What's the best way to get answers from my health plan?

A19: The first step in getting answers about your health benefits is to request information about your coverage from your human resource (HR) department. They will have pamphlets and brochures about your health plan that will give you some of the answers you need. If you have trouble understanding them, you can always meet with your HR director and go over your questions specifically. In addition, many health insurance companies have websites that provide consumers with easy-to-understand information. Lastly, you can always call your insurance company directly if you still cannot find the answers you need.

Q20: What do I do if I don't like my plan? Can I change it?

A20: In most employer-sponsored health benefits plans, Open Enrollment occurs once a year, which is why it is so important to research health plan options and make well-informed decisions. However, people who experience certain life changes such as marriage, divorce, the birth of a baby or death of a spouse are eligible to change health benefits at other times during the year. Check your plan's website to see what the guidelines are. In addition, many individual health plans allow members to change their coverage throughout the year.

Q21: What if I have a complaint against my plan, or want to file an appeal? How do I do this?

A21: Most health plans provide formal and informal ways for members to communicate their concerns with a health plan's decision. Consumers should start by contacting the member services department. Typically, health plans provide a toll-free member services number on the members' ID cards. If the issue cannot be resolved during the phone call, the customer service professional researches the inquiry and then responds to the member. There is an escalation process for members who are unsatisfied with the customer service professional's response. Members have the option of filing a grievance with their health plan or requesting a hearing and initiating an external review. Specific instructions for filing a grievance or appeal may vary by health plan. Visit your health plan's website for detailed instructions.