Idaho Health Insurance Shopping Guide

The Idaho Department of Insurance encourages consumers to shop around before selecting a health insurance plan. It is important to learn how an insurance plan works and what is and is not covered before you have a claim. Here are some suggested questions to discuss with insurance sales representatives to compare health insurance plans:

Is this insurance?

Is this a plan of insurance, or a discount services plan with "PPO benefits" or "membership benefits"?

Is the insurance company licensed by the Idaho Department of Insurance to do insurance business in Idaho?

Is the salesperson licensed as an insurance agent in Idaho?

What terms are used to describe the insurance plan? Major medical? Hospital/Surgical/Medical? Indemnity? Specified Disease?

What does the plan say about coverage for pre-existing conditions? Are there other waiting periods before certain illnesses or services are covered?

What expenses do I have to pay?

Does the plan have a deductible amount for each insured person? (That is, the amount each person must pay out-of-pocket before benefits will be paid)

Is the deductible:

• For each calendar year?
• For each admission into a hospital or surgical center?
• Is there a limit on the number of deductibles the plan will charge for all members of my family? Is that limit good for a calendar year or for a "benefit period"?
• Is there a separate deductible for some services, such as maternity?

Are there separate co-pays for some services?

• Doctor office visits.
• Use of emergency room if not admitted to a hospital.

Does the plan pay benefits:

• Based on a percentage of charges incurred?
• Based on a schedule of services?

Does the plan have different benefit levels if I use an in-network/participating provider or an out-of-network/nonparticipating provider? How easy is it to get a list of participating providers? Are my doctors, medical facilities, or pharmacies included as participating providers?

Does the plan include limits on the amount of my out-of-pocket expense?

Does the plan require pre-authorization and/or pre-certification for some procedures? Are there penalties if I don't pre-authorize or pre-certify treatment?