INSURANCE

Question: I heard that if both my wife and I have health insurance that covers our kids, something called "the birthday rule" applies. What does that mean?

Answer: Like many dual-income couples, you and your spouse have evidently included your kids on each of your group health insurance plans to maximize your benefits. However, without some sort of system in place to help the insurance companies coordinate benefits, it's possible that either you or your doctor would be reimbursed for more than 100 percent of the actual cost of your claim.

To prevent this, insurance companies typically designate one parent's health insurance plan as the primary plan and the other as the secondary plan. (That's why the patient questionnaire at your doctor's office asks for information on primary and secondary coverage.) The primary plan is responsible for paying covered expenses up to the limits of the policy. If any unpaid costs are left over, the secondary coverage kicks in.

The birthday rule is often used to determine which plan is primary and which is secondary. Under this rule, the plan of the parent whose birthday occurs first in the calendar year is designated as primary. The date of birth is the determining factor-not the year-so it doesn't matter which spouse is older.

Like most rules, the birthday rule has exceptions:

• If both parents share the same birthday, the parent who has been covered by his or her plan longest provides the primary coverage for the children.
• If one spouse is currently employed and has health insurance through a current employer, and the other spouse has coverage through a former employer (e.g., through COBRA), the plan belonging to the currently employed spouse would be primary.
• In the event of divorce or separation, the plan of the parent with custody generally provides primary coverage. If the custodial parent remarries, the new spouse's coverage becomes secondary. And finally, the non-custodial parent's plan would provide a third layer of insurance protection. This order of payment can be altered by a court-issued divorce decree or by agreement, but the insurance companies must be notified.

Keep in mind that these practices are common among insurance companies, but they are not governed by law. Practices may vary from one insurer to another. Read your policy carefully to make sure you understand how your insurance company handles dual coverage. If the policy language is unclear, ask for help from your employer's benefit specialist or your insurer's customer service department.

Question: I'm adopting a child with health problems. Will I have trouble adding him to my health insurance policy?

Answer: Whether the child you are adopting has health problems that can be corrected with proper treatment, or has a medical condition that will require ongoing care, you may be concerned that your health insurance provider will refuse to cover your child because of his pre-existing condition. But if you have group health coverage, take heart. The Health Insurance Portability and Accountability Act of 1996 bans group health insurance companies from excluding newly adopted children from coverage because of pre-existing conditions. The law also includes a "portability provision." If you change jobs and enroll in a new group insurance plan, the new insurance company must cover your adopted child.

Check with your health insurance provider, though, to make sure that the treatment the child will require is covered under your policy. If the provider does not normally cover the treatment for you or your naturally born children, it will not cover that treatment for your adopted child. Moreover, you generally must add your child to your health insurance plan within 30 days of either the adoption or the placement for adoption. Otherwise, your health insurance provider may deny coverage. You can usually do this by calling your health insurance company or informing your employer's human resources department. If your child is hospitalized when you legally adopt him, call right away to ensure that all medical claims are paid.

Question: Is there such a thing as chiropractic insurance?

Answer: In this day and age, you can probably find just about any type of insurance if you look hard enough. In addition to standard life, health, auto, and homeowners coverage, you can insure anything from your champion racehorse, to your favorite doll collection, to your pet iguana's health. So it's likely that somewhere, someone would be willing to sell you a chiropractic insurance policy. But chiropractic insurance is not a standard type of insurance policy that you could purchase from your neighborhood insurance agent.

That being said, you may be able to get coverage for chiropractic services through your regular health insurance plan. As they become more mainstream, chiropractic and other types of alternative medicine are gaining credibility with the health insurance industry. Although it is still not the norm, many insurance companies are now including coverage for chiropractic services. Certain other alternative medical treatments are also covered under some health insurance plans, especially if you are referred to an alternative medicine practitioner by your primary care physician (PCP).

To find out whether your health insurance covers chiropractic care, check your coverage information carefully or contact your insurance company's customer service department.

Question: If a company goes out of business, are the employees eligible for COBRA even though there is no longer a health insurance policy for the company?

Answer: In most cases, no. Under the Consolidated Omnibus Budget and Reconciliation Act of 1985 (COBRA), workers who lose their jobs may have the right to continue group health care coverage under their employers' plans. Unfortunately, however, if the company goes out of business and no longer has a group health insurance policy in force, then COBRA coverage is no longer available. One possible exception: union employees who are covered by a collective bargaining agreement may be entitled to COBRA coverage if the agreement provides for a medical plan.

The good news is that employees who are not eligible for group coverage under COBRA may still be able to obtain group health insurance elsewhere. For instance, they may find a new job with an employer who provides health insurance or may be eligible for employer-sponsored coverage through a family member's employer-sponsored plan. And, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the health coverage they had through their former employer may "count" towards reducing or eliminating any pre-existing condition exclusion that might apply when they seek group health insurance with another employer.

In addition, there are other sources of health insurance at opposite ends of the price spectrum: low-cost or no-cost health insurance coverage through a public program sponsored by their state's unemployment office or more expensive individual health insurance that can be purchased through insurance companies.

Question: Can I get disability insurance if I'm self-employed?

Answer: Yes. In fact, as a self-employed person, disability insurance may be even more important for you than for the average employee. If you suffer an injury and are unable to work, you don't have the built-in luxury of paid sick leave to tide you over. Thus, you should take a serious look at your financial situation and decide whether your cash reserves are sufficient to carry you through an extended disability. If not, disability insurance may be a good idea for you.

If you choose to purchase it, disability insurance could be the only thing that prevents you from losing your home, your business, etc. If you're unable to work for an extended period of time because of an injury or illness, disability insurance provides a financial safety net by paying you monthly benefits until you are able to return to work. Since your business is likely your only source of income, your disability insurance policy should have as short a waiting period as possible. Most disability policies have waiting periods of 30-180 days after the onset of the disability or illness, but you can typically negotiate for a shorter waiting period. Keep in mind, however, that your premium may increase as the waiting period gets shorter.

Since you can't get disability insurance through your employer, you will have to purchase it on your own. This is typically not difficult to do. In fact, many people purchase individual disability policies to supplement the coverage provided by their employers.

Question: I'm planning on living abroad for several months. Do I need special health insurance?

Answer: Taking an extended trip abroad requires an enormous amount of planning. Although it may not be foremost in your mind, your health insurance coverage is an important part of this planning.

Standard health insurance plans are generally not designed to cover extended periods of international travel. Most managed care plans do cover emergency treatment regardless of where it is administered, but other types of care are typically limited to a local network of providers. Health maintenance organizations (HMOs) may pay nothing if you seek routine care from a non-network provider, while preferred provider organizations (PPOs) generally cover only a portion of these costs. And most Americans do not qualify for the national health-care programs offered to citizens of many European nations. Before you go abroad, find out what coverage you will have. Tell your insurance company how long you will be overseas and what countries you will visit.

For some travelers, travel insurance may be an adequate solution. However, travel insurance may provide only limited coverage, typically for no more than six months.

If your stay abroad will last more than six months and you want to get the most comprehensive health insurance available, you may want to look into expatriate health insurance. Many larger insurance companies such as Lloyd's of London offer this type of insurance specifically for Americans living in other countries.

Expatriate health insurance plans can be customized in many ways. In addition to standard medical and emergency coverage, you can get a plan that includes maternity coverage, specialty treatments such as acupuncture and chiropractic, and even emergency evacuation. Choosing the right features depends on your family's needs, your financial situation, and your travel plans.

If you decide to purchase an expatriate plan, you can expect to complete an extensive application. You'll need to disclose any health problems your family members have had in the past 10 years, from broken bones to hereditary conditions to substance abuse. The cost of an expatriate plan varies depending on the features you choose, the number of family members to be covered, the age, sex, and state of health of each family member, your travel itinerary and various other factors.

Question: What is the difference between an HMO and a PPO? Which one is better?

Answer: Health maintenance organizations (HMOs) and preferred provider organizations (PPOs) are both types of managed health-care systems. There are differences between the corporate structures of each, but they are typically not important to the average consumer. However, several other important distinctions exist, including the following:

• HMO members must choose a primary care physician (PCP) from among the HMO member physicians. The PCP provides general medical care and must be consulted before you can see a specialist, who must also be part of the HMO. PPO members do not choose a primary care physician and can refer themselves to specialists.
• HMOs typically provide no coverage for care received from non-network physicians (with exceptions for emergency care while traveling, etc.). PPO members are not required to stay within the PPO network, but there is usually a strong financial incentive to do so. For example, the PPO may reimburse 90 percent of costs for care received within the network, but only 70 percent of costs for non-network care.
• HMOs typically do not set deductibles that must be met before insurance benefits begin (e.g., $5 or $10). Instead, HMO members often pay a nominal co-payment for care. In contrast, PPOs sometimes require members to meet a deductible (especially for hospitalization) and may have larger co-payments than HMOs.

So, which is better? Of course, there isn't one right answer; the best choice depends on your particular needs. For example, if you are considering an HMO, it's important to make sure that your physician is part of the HMO network (unless you are willing to see another physician). If not, a PPO might be a better choice, because you can still receive at least partial coverage regardless of network affiliation. You might also prefer a PPO if you have a medical condition that requires specialized care, because PPO members do not need a referral before seeing a specialist. However, if ongoing out-of-pocket costs are a major concern, an HMO is often a better choice, because there are no deductibles and co-payments are typically lower.

If you are fortunate enough to have a choice between HMO and PPO coverage, you will need to take some time to evaluate the coverage offered by each and determine which one best suits the needs of yourself and your family.

Question: do consulting as an independent contractor. What are my options regarding health and disability insurance?

Answer: As a self-employed person, you need health and disability insurance as much as anyone. Most people get these types of insurance through their employers, but unfortunately this is not an option for you. You're your own boss, but that also means you have to supply your own benefits.

Health insurance.  In terms of health insurance, your options may be limited to:

• Individual health insurance coverage purchased directly from a provider, or.
• Group coverage purchased through a professional association or civic group (e.g., trade group, Chamber of Commerce, etc.).

Individual health insurance covers medical expenses on an individual basis. When you apply for individual insurance, your "risk potential" may be evaluated through a series of medical questions and/or a physical exam in order to determine whether you qualify for health insurance and how much it will cost. Individual insurance is typically more expensive than group coverage, but it may also provide more freedom to customize the policy to suit your personal needs.

Most people get group health insurance through their employers, but you'll have to look a little harder to find group coverage. Trade and professional organizations sometimes offer group insurance coverage, as do some civic groups and churches. With group coverage, the premium from group insurance is calculated based on characteristics of the group as a whole. All eligible members of the group can purchase insurance coverage under the plan, regardless of age or physical condition.

Disability insurance.  Disability insurance for self-employed people is typically available through the same sources:

• Individual disability insurance coverage purchased directly from a provider, or.
• Group coverage purchased through a professional association or civic group (e.g., trade group, Chamber of Commerce, etc.).

You will probably have to meet certain standards relating to age, income, occupation, health, and lifestyle before you are issued an individual disability policy. You will pay more for individual coverage than for a group policy, but you often get more for your money. Individual disability insurance provides a policy tailored to meet your needs, and may have more liberal benefits than group coverage. For example, an individual policy may have a longer benefit period or may replace a greater percentage of your income than a group policy.

Trade or professional associations sometimes offer disability coverage to their members. Although it is group-sponsored, association policies are actually issued to individual group members who must prove insurability. Insurability standards for association members are sometimes relaxed, however, and you will find it easier to qualify for association disability insurance than for an individual policy. Premiums for an association-sponsored policy are initially less than for an individual policy, but after a certain term (five or ten years) the premium can rise and may eventually exceed the premium for an individual policy.

In addition, government-sponsored programs such as workers' compensation and Social Security provide some disability protection. Unlike other types of disability coverage, you don't have to pay a premium for these programs. However, you do finance some types of government disability insurance by paying taxes. Disability coverage under these programs is extremely basic, and should not be relied upon as your sole source of disability protection.

Question: My child is heading off to college this fall. What insurance issues does this raise?

Answer: As you send your children off to college, you probably have a lot of things on your mind - whether they'll eat right and get enough sleep, how to pay the tuition bills, what to do with that empty bedroom, etc. For most people, insurance concerns are pretty low on the priority list. But there are some important issues you should consider.

Issue #1. Health insurance - make sure your child is covered.  Your medical plan probably covers your children until they're somewhere between 20 and 24 years of age, regardless of whether or not they live at home. But if the plan is an HMO and your child's college is far from home, accessing an approved provider may prove difficult. As an alternative, consider purchasing health insurance coverage through your child's college. Many colleges and universities offer low-cost health insurance for students. Cost and level of coverage vary greatly from one school to the next, but school-subsidized health insurance is often less expensive than continuing coverage through your existing health plan. And since health care is typically provided on-campus, it may be easier for the student to access.

Issue #2. Homeowner's/Renters insurance - make sure your child's possessions are covered.  If your child lives in a dorm or other university housing, their personal property is typically covered under your homeowners insurance policy. Check your policy for coverage limitations on computers and stereos, if your child can't live without these. Once a student moves out of the dorms and into an apartment, they are usually no longer covered under your policy. Off-campus students should purchase a renters insurance policy to cover their possessions.

Issue #3. Auto insurance - make sure the car is covered.  If your child will be taking a car to school, make sure the car is properly insured. If the child owns the car, then the insurance policy must be in the child's name as well. If the child is "borrowing" a car from Mom and Dad, the child must be listed on the insurance policy. Some insurance companies may require the child to be listed as the primary operator, since the car is in the child's possession and not the parents'.

Question: What are the differences in the levels of care and coverage with long-term care insurance?

Answer: The phrase "long-term care" refers to a broad range of medical and personal services. Long-term care goes beyond standard hospitalization and nursing care, and includes all the assistance you could need if you are unable to care for yourself for an extended period of time. For purposes of long-term care insurance (LTCI), there are three levels of long-term care. It is important to understand the distinctions between these levels in order to ensure that the policy you buy includes the coverage you want:

• Skilled care.  Skilled care is continuous "around-the-clock" care required to treat a medical condition. It is ordered by a doctor and is usually delivered by a skilled medical worker (e.g., a registered nurse or professional therapist). A treatment plan is established and supervised by a doctor.
• Intermediate care.  Intermediate care is needed on an occasional basis (daily or a few times a week), but is not continuous. Trained medical workers under the supervision of a doctor provide it. Intermediate care is less specialized than skilled care.
• Custodial care.  Ninety percent of all long-term care is custodial care, which provides assistance with activities of daily living (such as bathing, eating, and dressing). It does not require a doctor's orders, and can be performed by someone without professional medical skills. For example, someone who needs reminders to take medication on schedule may need custodial care.

Most LTCI policies cover skilled, intermediate, and custodial care in licensed nursing homes. However, long-term care can be provided in a number of other places, including adult day care centers, assisted living facilities, hospices, and even your own home. LTCI policies may limit the additional facilities in which you can choose to receive care.

Benefit choices.  When you purchase a LTCI policy, you will have to choose the amount of coverage you want. Most policies provide a maximum dollar amount for each day of nursing home care. This is called a daily (or "per diem") benefit. Daily benefits are typically available in amounts ranging from $40 to $250 or more. Home care and other types of care may be covered at a lesser rate (typically 50 to 80 percent of the daily benefit amount). Some newer LTCI policies offer "pooled benefits" rather than per diem benefits, meaning that the policy provides a total dollar amount that may be used for different types of long-term care services.

You will probably also need to choose a benefit period, which is the maximum length of time that benefits will be provided (e.g., one year, three years, five years, etc.). After the applicable time limit has been reached, no further benefits are paid. Lifetime benefits are also available, but as you would probably expect, LTCI premiums are higher for policies with longer benefit periods. Some policies have different benefit periods for different types of care.

Question: I'm retiring soon and I'm concerned about the cost of medical care, especially prescription drugs. Will my Medicare coverage be enough?

Answer: It's good that you're looking ahead and trying to determine if your medical expenses will be adequately covered in retirement. Many Americans don't discover the gaps in their Medicare coverage until it's too late, and they are forced to pay out of their own pockets for medical expenses they assumed would be covered

Medicare coverage requires that you meet certain deductibles before coverage begins, and you must pay significant co-payments for many types of medical treatment. In addition, traditional Medicare does not offer a prescription drug benefit.

Because of these deficiencies in Medicare coverage, you may wish to consider purchasing a supplemental medical insurance policy called Medigap. Medigap is specifically designed to fill the gaps in your Medicare coverage. Although Medigap policies are sold through private insurance companies, they are standardized and regulated by state and federal law.

Under federal law, there are 10 standard Medigap plans, each of which must cover certain specified services. Medigap policies pay most, if not all, of your Medicare coinsurance amounts. Some also provide coverage for deductibles and services that are not covered by Medicare, such as prescription drugs and preventive care.

Because Medigap policies are standardized, there is no need to compare provisions of the policies offered by various insurance companies. However, you should still compare the insurance companies themselves, as an insurance policy is only as good as the company behind it. In addition, Medigap premiums will vary from one insurance company to another, so you may want to do some research to find the best.

Question: My Medicare HMO is getting out of the business, what should I do?

Answer: Each year, managed care organizations are allowed to choose whether or not they will remain part of the Medicare+Choice program. In general, they must notify the Health Care Financing Administration by July 1 if they aren't going to renew their contracts. Your HMO's decision to withdraw at the end of this year has left you with two alternatives.

First, you can return to the original fee-for-service Medicare plan and purchase a supplemental Medigap policy, or you can enroll in another Medicare managed care plan or a private plan, if one is available in your area.

You have until the end of the year to decide. Your HMO must continue to provide coverage through December 31, unless you switch to another health plan before that date. If you haven't taken any action by the end of the year, you will automatically return to original Medicare on January 1.

You should have received a letter from your HMO explaining your rights and listing health plans that are still available in your area. Read it carefully, because the rules that apply to switching Medicare health plans are complex. If you need help deciding which option is best or need additional information, call the Medicare hotline at (800) MEDICARE.

Question: Will my Medigap policy cover dental care?

Answer: Your Medigap (also known as Medicare supplement insurance) probably won't cover dental care. Dental care is not one of the services covered under any of the 10 standard Medigap policies available in most states. However, under federal law, states can permit insurers to add "new and innovative" benefits to standardized Medigap plans, so it's possible that dental care could be covered by your Medigap policy. Read your policy or check with your insurance company just in case.

Even if dental care isn't covered, you still have other options. For instance, you may be able to purchase dental insurance from a private insurer, or if you or your spouse is still working, from an employer. Group associations and organizations also commonly offer dental insurance to their members. If it's available to you, think about purchasing dental insurance if you anticipate needing costly dental care.

Question: Do companies offer nursing home insurance? Is that offered in a long-term care policy? What is usually covered in long-term care policies?

Answer: "Nursing home insurance" is really just another name for Long-term care insurance (LTCI). However, nursing home insurance is an inaccurate term, because LTCI typically covers much more than just nursing home care. Long-term care insurance (LTCI) is a relatively new insurance product, so many consumers don't understand exactly what it covers.

Many insurance companies today offer LTCI products. Coverage for nursing home care is an important aspect of a complete long-term care policy, but it is not the only reason for purchasing LTCI. Most long-term care is provided outside the nursing home setting, so it is important to choose a policy that will cover the types of care you are most likely to need. Home health care, respite care, adult day care, assisted-living care, and many other types of care may be covered under a comprehensive LTCI policy.

When you purchase a LTCI policy, you are typically asked to choose the amount of coverage you want. Most policies provide a certain dollar amount for each day of care (called a "per diem benefit"), which can range from as little as $40 per day to $300 per day or more. Some newer LTCI policies offer "pooled benefits" rather than per diem benefits, which means that the policy provides a total dollar amount that may be used for different types of long-term care services. Pooled benefit policies usually include a daily, weekly, or monthly limit on covered expenses. You will also need to choose a benefit period, which is the maximum length of time that benefits will be paid. Some policies have different benefit periods for different types of care. For example, a policy might offer five years of nursing home coverage and two years of assisted living coverage. As you would probably expect, LTCI premiums are higher for policies with larger benefit amounts and longer benefit periods.

Question: Are health insurance companies required to pay for infertility diagnosis and treatment?

Answer: Infertility coverage is a hotly debated topic among insurance companies, consumer rights advocates, employers, pharmaceutical companies, religious groups, and many others. At the moment, there isn't one right answer to this question.

More than a dozen states have passed some sort of legislation regarding infertility coverage. Some of these states require that health insurance plans provide some level of infertility coverage. Other states require policyholders to offer some coverage for infertility, but give the applicants the option of refusing the coverage. The remaining states have no regulations mandating coverage for infertility diagnosis or treatment.

In states that mandate coverage, the level of required coverage varies. Some states allow insurers to impose a lifetime benefit cap, some limit the length of required coverage, and some permit them to require a co-payment.

Not every health plan is subject to state regulation. Individual and employer-sponsored health insurance plans bought through insurance companies are subject to state regulation. However, health insurance plans sponsored by employers who self-insure are not. Certain other types of health coverage, such as those purchased by churches and other nonprofit groups, are also not subject to state regulation. Health plans not subject to state regulation may voluntarily provide infertility benefits, but you'll have to check with your insurance company to find out.

Question: I own a pet and my vet bills are sky-high. Is there such a thing as health insurance for animals?

Answer: Yes. Due to the high cost of veterinary care, pet health insurance has become increasingly popular in recent years.

The health insurance that you purchase for your pet operates much like your own health insurance, with deductibles, co-payments, pre-existing condition limitations, and annual premiums. Coverage typically includes routine exams and vaccinations, as well as treatment for injuries and illnesses.

When shopping around for pet health insurance, make sure that the insurance company is recognized by your veterinarian and sells a licensed product. Keep in mind that coverage and policy types vary from company to company. In addition, you'll want to find out about policy limitations or exclusions (e.g., older pets, pre-existing conditions, etc.).

The cost of a pet health insurance policy will hinge upon a variety of factors, such as species, age, and where you live. But it is generally more affordable to buy pet health insurance than pay the full cost of veterinary care out-of-pocket. Some insurance companies may even offer discounts if you insure more than one pet with them.

Question: I'm planning to change jobs, but I'm also pregnant. Should I be concerned about qualifying for health insurance coverage?

Answer: Federal law provides some degree of protection for pregnant women who change jobs. Under the Health Insurance Portability and Accountability Act (HIPAA), pregnancy cannot be considered a pre-existing condition for a woman who is changing jobs if she was previously covered by a group health insurance plan. So if you had insurance at your old job, you can't be denied health insurance coverage at your new job simply because you're pregnant. However, this doesn't necessarily mean your worries are over.

Although most health insurance policies provide coverage for maternity care and pregnancy, it's important to check the specifics of your new employer's health insurance plan to make sure you are covered. HIPPA doesn't protect your right to maternity and pregnancy coverage if your employer doesn't offer it.

If you didn't have health insurance before you started your new job, or if you were covered by an individual health insurance policy, you do not qualify for the protection offered under HIPAA. In this case, you might be subject to a pre-existing condition waiting period under your new employer's health insurance policy.

Many companies also require you to be employed for 30 days or more before you become eligible for coverage. That may not be a problem if you are early on in your pregnancy and have the resources to pay for one or two prenatal visits out of your own pocket. If you are nearing the end of your term, however, a few weeks without health insurance could be financially disastrous.

You may be eligible for coverage under COBRA (Consolidated Omnibus Budget Reconciliation Act) through your former employer. However, this will generally require you to pay the full premium.

Keep in mind that some employers don't provide health insurance coverage at all. And being caught without group health insurance can be a serious problem for a pregnant woman. Individual coverage may be an option, but you may find it difficult to find an insurer who will cover you if you're already pregnant. In addition, the premiums on such a policy could be extremely high.

As you can see, it's important to do some careful planning before making a career move when you're pregnant. To protect your health and the health of your baby, make sure you completely understand the employer's health insurance plan and eligibility requirements before accepting a new job.

Question: Do I need prescription drug coverage if I already have major medical coverage?

Answer: Major medical insurance generally does include prescription drug coverage, so a separate prescription plan is usually not necessary. However, not all major medical plans are alike. In order to make sure that your medical insurance is sufficient, you'll need to read your policy carefully and find out exactly what it covers.

Even if your major medical plan includes prescription drugs, it may not provide all the coverage you need.

There are actually two distinct types of major medical: Supplemental major medical,  which only provides coverage after your regular medical insurance has been exhausted, and Comprehensive major medical,  which is a complete, self-contained medical policy.

Supplemental major medical is used to pick up where basic medical insurance leaves off. In order to utilize supplemental major medical insurance, you would first need to purchase a basic health insurance plan. When this coverage is exhausted, your major medical coverage would begin paying. Supplemental major medical coverage is often written in a separate policy, and does not include coverage for basic doctor visits, etc.

In contrast, comprehensive major medical plans generally include all the basic types of coverage:

• Hospital expense insurance: Pays your room and board costs if you are hospitalized (including intensive and cardiac care), as well as incidental expenses such as use of the operating room, x-rays, drugs, anesthesia, and laboratory charges.
• Surgical expense insurance: Pays surgeons' fees and related costs associated with surgery, including fees for an assistant surgeon, anesthesiologist, or even the operating room when it is not covered as a miscellaneous hospital item.
• Physicians' expense insurance: Sometimes called "regular medical expense insurance," pays for visits to a doctor's office, doctor's house calls, or doctor's hospital visits.
• Major medical: Offers extremely broad coverage with a very high maximum benefit. Most major medical provides at least $250,000 of coverage, although $1,000,000 or more in coverage is preferable. Coverage varies from one plan to another, but most major medical includes coverage for nursing services, anesthesia and anesthesiologists' fees, ambulance service, laboratory and diagnostic tests, radiology and other therapy, blood, plasma, oxygen, dental treatment resulting from injury, prescription drugs, outpatient services, convalescent nursing home care, home health care, casts, splints, crutches, and braces.

If you have a comprehensive major medical plan, your health insurance needs are most likely satisfied, so there's probably no need to get a separate prescription drug plan. However, you should still consider whether other types of health-related coverage (such as disability insurance and long-term care insurance) are appropriate for you. If you have a supplemental major medical plan and you need prescription drug coverage, consider purchasing a separate plan to meet this need.

Question: How much does prescription insurance usually cost, and does it include prescription delivery?

Answer: Prescription insurance, often referred to as a prescription drug plan, is an insurance policy that covers all or part of the cost of prescription medications. Prescription drug plans can be purchased on an individual basis or can be offered as part of a group-sponsored health benefit package. Most health insurance plans have provisions for prescription drugs. However, if your current health insurance policy provides insufficient prescription drug coverage, or if you have no drug coverage at all, you may wish to consider a prescription drug plan as a supplemental source of protection.

It is important to note that some prescription insurance plans are true "insurance plans" where you pay a deductible and/or a co-payment for prescriptions. Others are merely discount programs where you pay for the drug yourself but at a lower price. The cost of prescription insurance varies, depending upon the plan that you choose and your individual circumstances. Prescription insurance plans that are purchased on an individual basis are generally more costly than those that are offered through a group-sponsored plan.

Many prescription drug plans have a mail service component that allows participants to have prescription drugs delivered by mail. This service is often used for "maintenance" medications (drugs that are used on a daily or routine basis). Some plans offer even greater discounts on prescription drugs ordered through the mail.

Question: I am in between jobs and need short-term medical insurance. How broad is the benefit coverage under short-term medical insurance?

Answer: Short-term medical coverage is designed to fill the temporary coverage gap that can occur when you are between permanent plans. Such a gap can occur when you are between jobs, laid off, or waiting for group coverage, among other reasons. You and your dependents may be eligible for coverage if you meet certain age, health, and U.S. residency requirements.

To keep the premiums affordable, coverage is not as extensive as that under permanent plans, but it generally covers basic charges in the event of an accident or sudden illness. Like other medical insurance plans, short-term medical coverage may subject you to co-payments and benefit limits.

Generally, short-term medical plan coverage includes:

• Your choice of doctors and hospitals.
• Charges for inpatient and outpatient services provided by medical professionals.
• Hospital room and board charges.
• Intensive care unit charges.
• Ambulance services.
• Diagnostic lab exams and x-rays.
• Prescription drugs.

Generally, short-term medical plan coverage does not include:

• Preexisting conditions.
• Routine medical exams.
• Dental care.
• Pregnancy and childbirth expenses.
• Intentionally self-inflicted injury.
• Expenses not medically necessary.
• Medical expenses outside the U.S.

Short-term medical coverage is typically available for periods of 30 to 180 days, although some plans offer initial coverage for as long as 12 months. While you may be able to renew your plan, generally short-term coverage cannot continue for more than 365 total days.

In addition to insurance agencies, professional organizations and associations sometimes offer short-term medical insurance. Coverage can often be implemented quickly, sometimes the same day that your application is received. Many insurance companies offer a choice between a single payment or a monthly premium, as well as a choice of plan deductible limits. There may be a free look period (usually the first 10 days after delivery of the policy) during which you can cancel your policy for a full refund.

Question: As a single parent, what can I do to make sure my child's health insurance needs are covered?

Answer: As a single parent, you'll probably find that the most cost-effective way to provide health insurance for your child is to add him or her to an existing employer-sponsored health insurance plan. The cost of this option will vary, depending on the type of coverage the employer offers and whether the employer pays all or part of the cost. Find out if your employer offers employee child coverage; typically, this type of coverage is significantly less expensive than family coverage.

In some cases, you may be better off seeking out an individual health insurance policy for your child. Some insurers offer specialized policies designed just for kids. This coverage may be somewhat expensive for infants (because they require so many doctor's visits for immunizations, checkups, etc.), but the cost generally drops after the child's first year.

Health insurance coverage for your child becomes a bit more complicated when you are a single parent who is divorced. You'll need to figure out whether your health plan or your ex-spouse's health plan is responsible for paying your child's health-care claims. If your child is covered by both health plans, generally the plan of the parent who has custody pays the child's health-care claims first, while the plan of the parent who does not have custody pays second. However, if a divorce court has stipulated which parent is responsible for the health-care expenses of the child, the responsible parent's health plan pays the child's health-care claims first.

Question: I belong to an HMO, but I would like to see a specialist who is outside of my provider network. What are my options?

Answer: When you belong to an HMO, your choice of specialists will be limited to a group of doctors to whom your primary care physician (PCP) provides referrals. Although you'll normally be referred to a specialist who can treat you satisfactorily, a problem may arise when you would prefer to see a particular specialist who is outside of your PCP's network.

If you decide that you must see a specialist outside of your PCP's network, first ask your PCP for a referral. If your primary care physician is reluctant to provide a referral, explain to him or her exactly why you want to see that specialist. If your PCP will not provide the referral, and you feel strongly about seeing the out-of-network specialist, you have two options:

• Pay for the specialist's services out of pocket.
• Change to a primary care physician who will make the requested referral (most HMOs allow you to change PCPs).

If your PCP does make the referral, your HMO can still refuse to pay for your visit to the specialist. In this case, you should appeal directly to the HMO and explain why you wish to see that particular specialist. If you are persistent, you can sometimes get an HMO to pay for a service that was previously denied. If your appeal fails, you can pay for the specialist's services yourself or see a specialist whose services will be covered by your HMO.