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Health Insurance Plans

Welcome to English as a Second Language Podcast number 269: Health Insurance Plans.

This is English as a Second Language Podcast episode 269. I’m your host, Dr. Jeff McQuillan, coming to you from the Center for Educational Development in beautiful Los Angeles, California.

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This episode is called “Health Insurance Plans.” In the United States, as you may know, most people have private health insurance; there is no national health insurance. This story is about the kinds of health insurance plans that you can have, and the problems that sometimes happen when you have to use the hospital or go to a doctor. Let’s get started!

[start of story]

At my company, I have a choice of health insurance plans. We can pick between HMOs and PPOs, and I have been with the same managed health plan for the past few years. It’s the plan that has the lowest co-pays and the best coverage, and the network of doctors is fairly large. The drug coverage is good and the affiliated hospital is close to my house. Unfortunately, I’m discovering that it’s also the plan with the largest bureaucracy and patients can easily get lost in the shuffle.

I have a primary care physician, but like other plans, if I want to see a specialist, I must be referred by my primary care physician. I’ve been trying to see an eye specialist for a few weeks. I called my doctor’s office for a referral, but the nurse told me that I needed to first make an office visit. I tried to get an appointment, but there weren’t any openings for five weeks! I tried to leave a phone message for my doctor to talk to her about my situation, but she never returned my call. I tried several more times, and still received no response.

I finally decided to file a grievance. I know that I have patient rights, and that if I didn’t feel I was being treated fairly, I could file a complaint. I just hope that filing the grievance will get me a resolution to this problem. I’d like to see an eye specialist before I go blind!

[end of story]

The story begins by me talking about how I have a choice of health insurance plans. I can pick between an “HMO” and a “PPO.” These are two kinds of health insurance plans that you can get from the place where you work or you can buy on your own. “HMO” stands for “health maintenance organization.” “Maintenance” comes from the word “maintain,” which means to keep your health, in this case. “To maintain something” means to support it; to make sure that it continues to be good. So, “health maintenance organization” is an organization of doctors and hospitals that work, usually, with a specific company – an insurance company – and they give a discount – a lower price – because they work in this organization. It’s usually less expensive than the other kind of plan called the “PPO.” An HMO is the most common health insurance plan in the United States; most people have these plans. You can only choose the doctors who are part of the plan, however, and you can only go to certain doctors and certain hospitals. So there is less choice when you have an HMO, but it is cheaper.

A “PPO” stands for “preferred provider organization.” A “provider” (provider) is a person that gives you something or provides you with some service. In this case, doctors are the ones who are the providers, and hospitals. A “preferred provider organization,” or “PPO,” is an organization that also works with a – an insurance company and offers their services, but you have a lot more choice. You can see any doctor, or almost any doctor you want to. However, it’s more expensive, so you have to pay more for a PPO.

I say in the story that I’ve been with the same managed health plan for the past few years. A “managed health plan” is a general term for HMOs and PPOs. It’s any plan that helps you get health care for a lower price. I say that the plan I have, which is an HMO, has the lowest co-pays and the best coverage. A “copay” (co-pay) is the amount of money that you have to pay the doctor or the hospital every time you have an appointment. Usually it’s it a low amount: $10, $20, maybe $30. Every time you go to the doctor, you have to pay this minimum fee of 15, 20, $30. When I go to my doctor, I have to pay my co-pay of $15, and my insurance – my health insurance – takes care of the rest of the cost. Of course, I have to pay for my health insurance every month, and so does my company.

In the story then, I say that the plan I am with has the lowest co-pays – the least expensive co-pays – and the best coverage. “Coverage” (coverage) means the number of different types of medical care that the plan will pay for. So it will pay for, for example, surgeries, and problems you might have with your skin, and all the different kinds of medical problems you could have. A plan with good coverage covers, or pays for, many things.

My health plan also has a large network of doctors. A “network” (network) in this case means a group of people who are connected to each other, usually who have some sort of common interest or talent. So, a “network of doctors” are a group of doctors that work with each other. The word “network” has a couple of different meanings in English; take a look at our Learning Guide today for additional explanations.

The story continues that drug coverage is good with my plan, and the affiliated hospital is close to my house. “Drug coverage” just means the different kind of drugs that the insurance plan will pay for. An “affiliated (affiliated) hospital” is one that is connected to, or associated with. In this case, it’s the hospital associated with my health plan.

Unfortunately, I say that I’m discovering that it’s also the plan with the largest bureaucracy and that patients can easily get lost in the shuffle. A “bureaucracy” (bureaucracy) is a complicated organization, usually a business or a government organization, that has very difficult or complex rules that you have to follow. The word “bureaucracy” is often a negative term to describe an organization that is too complicated.

I say that patients in my health plan can get lost in the shuffle (shuffle). The expression “to get lost in the shuffle” means not to receive the attention that you need because there are so many other people. Many American high schools, for example, have 2,000 or 3,000 students; it’s easy for the students to get lost in the shuffle. Because there are so many students, they don’t get the attention that they need.

I say that I have a primary care physician. A “primary care physician” is the doctor whom I see regularly; the one I normally see. It’s usually a doctor that knows a lot about many different things. The opposite of a “primary care physician” would be a “specialist” (specialist). A “specialist” is a doctor who only works on one type of medical issue or problem. It could be a heart specialist or an eye specialist or a foot specialist.

I say that, in the story, if I want to see a specialist, I must first be referred by my primary care physician – my regular doctor. To be “referred” (referred) means the doctor says, “It’s okay, you can go and see the specialist.” In order to get a referral – in order to be referred by my doctor – I have to first make an office visit.

An “office visit” is an appointment with the doctor or a dentist where you go into their office and talk to them personally – you have to visit the doctor.

I tried to get an appointment, but I found out that there were no openings for five weeks. An “opening” (opening) – or an opening, to pronounce it the way most people do – is an available appointment; it’s a time when you can go and see the doctor. If the doctor says she doesn’t have any openings for five weeks; that means there are no appointments that are free – no time for you to go see the doctor for five weeks.

I called the doctor; the doctor did not return my message. I should mention that this story is actually based upon something that really happened to me a few weeks ago, so this is my way of complaining, by telling the story. So, I decided to file a grievance. A “grievance” (grievance) is a complaint; when you say that there is something wrong and you tell the company or the organization.

I have patient rights (rights). A “right” is something that you should be able to do; something that you are allowed to do that is guaranteed to you. I’m hoping that my grievance will give me a resolution to this problem. A “resolution” (resolution) is a solution. “Resolution” has other meanings in English as well; again, take a look at our Learning Guide today for more explanations.

I end the story by saying that I would like to see an eye specialist before I go blind. “Blind” (blind) is when you cannot see at all.

Now let’s listen to the story, this time at a normal speed.

[start of story]

At my company, I have a choice of health insurance plans. We can pick between HMOs and PPOs, and I have been with the same managed health plan for the past few years. It’s the plan that has the lowest co-pays and the best coverage, and the network of doctors is fairly large. The drug coverage is good and the affiliated hospital is close to my house. Unfortunately, I’m discovering that it’s also the plan with the largest bureaucracy and patients can easily get lost in the shuffle.

I have a primary care physician, but like other plans, if I want to see a specialist, I must be referred by my primary care physician. I’ve been trying to see an eye specialist for a few weeks. I called my doctor’s office for a referral, but the nurse told me that I needed to first make an office visit. I tried to get an appointment, but there weren’t any openings for five weeks! I tried to leave a phone message for my doctor to talk to her about my situation, but she never returned my call. I tried several more times, and still received no response.

I finally decided to file a grievance. I know that I have patient rights, and that if I didn’t feel I was being treated fairly, I could file a complaint. I just hope that filing the grievance will get me a resolution to this problem. I’d like to see an eye specialist before I go blind!

[end of story]

The script for this podcast was written by Dr. Lucy Tse.

From Los Angeles, California, I’m Jeff McQuillan. Thanks for listening. We’ll see you next time on ESL Podcast.

English as a Second Language Podcast is written and produced by Dr. Lucy Tse, hosted by Dr. Jeff McQuillan. This podcast is copyright 2007.