"Self Employed Health Insurance : Health Insurance in Oregon
Private Health Insurance : Medical Plans : Health Insurance Quotes"

Why have health insurance wether it be a self employed, private, Oregon or medical plans?

Simply put; without it you may get NO care, you may be charged up to 3 times the cost insured patients are charged, you may be forced into medical bankruptcy because of the cost of an uninsured medical event ( go to: www.orpricepoint.org You can look up the cost of hopitalization in Oregon for most illnesses & surgeries), to preserve your own peace of mind, you may deny yourself the medical care you need and you could be "dumped".

What's this? Dumping is where a hospital stabilizes uninsured emergency patients and then has them taxied to a small nonprofit community hospital or a homeless shelter so they do not have to spend the money on expensive procedures.

Don't believe hospitals do this in America? Rent "Sicko" a DVD by Michael Moore in your local video store and see for yourself.

Hospitals, whether they are for profit or nonprofit they need to make a profit to keep running, No organization can run at a loss for long unless they are the government.

If you are the administrator of a hospital and you have three patients, one with private insurance, another with slow and low paying medicare or an inferior program, the third with no insurance. Which is going to get served first, the most, and receive the best care?

You insure your home, apartment contents, your car, your business. Are you not the most important "thing" in your life? That's the real reason to be properly covered. Read on and learn how to choose the best care for you and your family.


The sole purpose of this site is to assist you in finding the proper healthcare policy to fit your needs and budget. Everyone should have insurance, it is the best way to assure access to proper medical care. Self Employed, in Oregon, Private & Medical insurance plans all have advantages for you.
This information will help you make the right choice for your needs & budget.

Since you may use this product at the worst of times it is very important to fully understand health insurance systems because they are not all the same and many hide restrictions and limitations of benefits in the policy, never mentioning them in the sales presentation, the online literature or brochures they send you.

The unknown secrets, tricks, pitfalls and advantages of healthcare insurance are revealed here so you can make the right purchase for you, your family and your business.

Take the time to read through this information before signing up online or through an agent. Health insurance is a complex product. You want to purchase what will properly protect you.


Who determines the care you receive?
Managed and Non-Managed Health Insurance Programs.

Simply put, managed care is where an insurance company, not your physician decides what care you will receive. These type of policies are common in the Low Cost or Cheap product arena.

This entails pre-admission authorization and referral requirements before care is paid for or allowed. (example: you have an emergency, are in a coma, need an ambulance or life flight ride to emergency at a hospital. If you do not call beforehand and get permission or approval for this event the insurance company can refuse to pay and most times will not.)

Other reasons for refusal to provide care: drugs too costly, condition not serious enough to warrant care in insurance companies opinion, insurance company doesn't think doctor's recommendations valid, policy has restrictions allowing insurance company an "out" to not pay for procedure or care. Please note this list is not complete just a sample to give you an idea of the power an insurance company has in a managed care system.

These are pure HMO and PPO systems. They have networks of doctors and hospitals you have to go to. If you go outside of these networks, you end up paying more for your care or receive no payment from the insurance company.

In a non-managed care insurance policy the company is usually restricted to having a say as regards the "medically approved procedure" category, i.e., is the procedure approved by the FDA, AMA, etc. This prevents the insurance company from paying for care from non-licensed providers or those outside of the medically approved field, say a VooDoo Doctor. A non-managed care system allows you to choose the doctor, hospital and care of your choice without permission from the insurance company.


How can I control costs? Will I be stuck with extra charges?

Insurance companies have two ways they determine how much they will pay for your doctor and hospital costs. The most common is "Usual, Customary and Reasonable". In this payment scheme the insurance company pays an amount THEY determine is "reasonable". This amount is determined totally independent of the actual cost of the service. This forces doctors and hospitals into a "discount" situation & limits the number of facilities and doctors you have access. The second system is "Usual and Customary"

There are two categories of Usual, Customary and Reasonable:

Preferred Providers These are doctors and hospitals who agree to provide services at the discounted rates and not charge you the difference between their normal charge and the discounted payment. (Affordable, Low Cost & Cheap policies)

Participating Providers The discounted fee is accepted but the doctor or facility "back bills" the patient for the amount the insurance company did not pay. This group usually includes specialists, highly experienced surgeons & medical teams, facilities that specialize in cancer, heart, neuro-disibilities & life threatening sicknesses or injuries, to name a few. (Low Cost & Cheap policies)

The reason they do not accept the discounted amount as final payment is they are the providers who are at the top of their game and don't need to accept discounts as they are already too busy and have a waiting list for new patients. They are the best in their field and the ones you want access to for you and your family.

Usual & Customary is defined as:

The charge that is the smallest of: 1) the actual charge; 2) the charge usually made for the covered expense by the provider who furnishes it; and 3) the prevailing charge made for a covered expense in a geographic area by those of similar professional standing.

Number 3 is the most important to you as it has an adjustment feature built in. If you have a procedure in another state where the cost of living is greater than Oregon, the amount paid has to adjust to what is normally charged there. So there is no disadvantage to you cost wise to seek out the best care available with "usual and customary" systems. (Self Employed, Private & Medical insurance plan policies)


Deductibles and Premiums - Why do I have to pay both?

Because insurance companies want to do all they can to keep you from using the coverage, charging premiums and having deductibles is a common method. If you have to pay to get care you are less likely to make that appointment. (Low Cost & Cheap policies)

Here's how it works. You have access to doctor's office visits with a co-pay but anything beyond that comes under the deductible and you have to pay the deductible amount in full first before you get care paid for my the insurance company

Let's say you have a $300. month premium with a $1,200 deductible. Your doctor orders $800 in testing. Who pays? YOU do. Why? The $1,200 deductible has to be paid in full first before the insurance starts paying and $800 is less than the deductible amount.

In reality your premium is really $400 a month. How is that? Since you have to pay off the deductible before getting care beyond doctor office visits, it has to be added to your monthly premium. ($1,200 / 12 = $100 + $300 (monthly premium) = $400. If your deductible is higher the effect is greater.

A $200 a month premium with a $6,000 deductible = $700 month. ($6,000 / 12 = $500 + $200 (monthly premium)

What can you do to avoid this extra cost? This solution is to find a system that only charges you a deductible for hospitalization related services & does not charge it when you go to the doctor, have a minor accident issue, purchase medications, dental, vision or physical therapy care. Only a couple of these programs exist in Oregon but they are great plans. ( Some Self Employed, Private & Medical insurance plan policies)


Why can't I get the care my doctor ordered? How can the insurance company say NO!

Welcome to Referral Requirements and Pre-Admission Authorization. (Low Cost & Cheap policies)

Referral Requirements require your doctor to ask permission from the insurance company before they can provide you access to specialists of any training. If the insurance company does not think you need to see a specialist for your condition, they won't allow the referral and will not pay. O, you can still see the specialist, but YOU have to pay for it.

Pre-Admission Authorization is a system where you HAVE to call the insurance company and get permission before getting care, if you don't they will not pay. This applies to any inpatient or outpatient surgery, physical therapy, cancer treatment, transplants, special medications and emergency to name a few. Emergency! Yes. If you have an emergency, in a coma, are placed in an ambulance and taken to emergency without calling the insurance company first, they can and will refuse to pay

Why would an insurance company have such restrictions? So they can reduce their costs. If they have the power to say no and you need something expensive they are going to try and find other cheaper ways to deal with you until they run out of cheap options, you die or drop them.

How can I and my doctor have control of my care? Buy insurance from a company that does not have these requirements. Sounds simple but most agents do not share this information with potential clients and most policy holders (you) never read their policies so they find these things out when they need the care the most and can't get it. (Some Self Employed, Private & Medical insurance plan policies)


I'm self employed will an insurance company pay for on-the-job injury or sickness?

Most plans in Oregon have a clever exclusion so they do not have to cover the self employed. Why? Because the self employed work longer hours then company employed individuals and they are generally not covered by workmans comp. This is a high risk factor for insurance companies that they want to avoid.

How do they do this? By having a restriction that basically says, "If you are working for wage or profit and are not legally exempt from workmans comp. you will not be covered" Most self employed are in this situation. Just because you choose to not be covered by workmans comp. does not mean you are legally exempt. Only certain classes of workers are legally exempt.

So what? If have such a policy and you are injured or become sick because of the work you do, the insurance company can legally refuse to pay for your medical care. That's what! If you lie about it ( it happened at home) and the insurance company later finds out, they can make you pay back every penny they spent for your care & sue you for fraud.

Solution: Buy insurance that does not have this limitation and covers you 24/7 whether working or not. Make sure it states you are covered in the presentation information or policy, don't take the agent's word. In court, the printed material & the policy rules.


Who has the right of Renewal? It better be YOU!

Why: You could lose coverage & not be able to get it back if you don't. Why do insurance companies reserve the right to renew your coverage yearly? Cost containment. If you have developed medical issues they do not want to pay for anymore they can choose to cancel you.

If they refuse to re-issue your policy & you re-apply to another company, there is a question on all Oregon Application forms that asks; "Have you every had health coverage refused, cancelled or not renewed? If yes, What Company?" They will take this information & ask the other insurance company why. What do you think your chances of getting new coverage are then? (Low Cost & Cheap policies)

Solution: Buy insurance that does not have this limitation (Usually printed on the face of policy). Make sure you have an actual contract with the insurance company not just a subscription to their plan. With subscription plans the insurance company can change benefits at will. (Some Self Employed, Private & Medical insurance plan policies)

Helpful Links
Premier Plans - Lower Your Medical Costs Programs