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0269 Health Insurance Plans

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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.

Check out our website at eslpod.com, and take a look at the Premium Courses we have in our ESL Podcast Store.

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 “co-pay” (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.

Glossary
HMO – health maintenance organization; an organization of doctors and hospitals that work with a specific insurance company and offer their services for a set price; individuals must always see a doctor within the organization and see their main doctor first, but it is less expensive than using a PPO

* Anatole wanted to see a specialist for his stomach pain, but he had to go to his regular doctor first because he’s a member of an HMO.


PPO – preferred provider organization; an organization of doctors and hospitals that work with a specific insurance company and offer their services for a set price; individuals can see any doctor, but it is more expensive than an HMO

* Mel pays a lot for his PPO, but he likes being able to see any doctor whenever he needs to.


managed health plan – any plan that helps members get health care for a lower cost, especially if there are medical emergencies

* If healthcare is important to you and your family, before you accept a new job, ask the employer what kind of managed health plans are available.


co-pay – the amount that a person who has health insurance must pay each time he or she has a medical appointment

* Ulysses has a $10 co-pay every time he goes to the dentist.


coverage – the number of different types of medical care that a health insurance plan will help people pay for

* This health insurance plan includes coverage for mental health counseling.


network – a group of people who are connected to each other and communicate and share information with each other

* Is there a national network of elementary school teachers?


drug coverage – the number of different types of medicines that a health insurance plan will help people pay for

* Dion’s health insurance plan has horrible drug coverage. He had to pay the full price for all the medicine that he needed last year.


affiliated – officially connected with something else; officially in a business relationship with something else

* Don’t forget to put on your resume a list of the professional organizations that you’re affiliated with.


bureaucracy – a complicated system of rules that a business or government agency follows that make it operate very slowly

* Private companies can usually work faster than government agencies because they don’t have such large bureaucracies.


to get lost in the shuffle – to not receive the attention that someone or something needs because there are many other people or things in the system

* Applying for a work visa is difficult because the applications often get lost in the shuffle, and it can take months to get a response.


primary care physician – the doctor whom one regularly sees; a general doctor who can provide medical care for most common health problems

* I have been with my primary care physician for ten years because she’s a great doctor.


specialist – a doctor whom one sees only for a specific type of health problem; a doctor who has a lot of training in a specific type of medicine

* When Rebecca hurt her back during soccer practice, she had to make an appointment with a back specialist.


to refer – to recommend that someone speak with a specialist about a specific health problem

* When the doctor couldn’t figure out what was wrong with Conrad’s skin, he sent him to a dermatologist who was an expert in skin diseases.


office visit – an appointment with a doctor or dentist where one goes to the medical office and speaks with the doctor or dentist in person

* The doctor would not prescribe something for my headache unless I made an office visit so he could examine me.


opening – an available appointment; a time when a doctor is available to meet with a patient; an open period of time on a doctor’s calendar

* Dr. Brenson has openings at 3:00 and 4:45 that day. Which would you prefer?


grievance – a complaint about something that isn’t fair or that is against the rules

* Adel filed a grievance against her employer because she says that the company pays women less than it pays men.


right – something that one should be able to have or do because it is good, true, or fair; a privilege given to a person or a group of people

* Do people under the age of 18 have the right to vote in this country?


resolution – a solution or end to a problem or argument

* The two countries are going to war because they can’t find a resolution to their problems.


blind – unable to see anything because one’s eyes don’t work properly

* Alina was born blind, so she has always used a dog to “see” for her while she’s walking outside.

Comprehension Questions
1. What is good about the health plan that the person in the story uses?
a) It has good coverage.
b) It requires referrals.
c) It is a bureaucracy.

2. Why hasn’t the person in the story been able to meet with a specialist?
a) Because the specialist doesn’t have any openings for five weeks.
b) Because meeting with a specialist isn’t one of the patient rights.
c) Because the primary care physician is too busy to give a referral.

Answers at bottom.

What Else Does It Mean?
network

The word “network,” in this podcast, means a group of people who are connected to each other, sharing information and communicating with each other: “Websites like MySpace and Friendster can help you create networks of friends.” A “network” is also a group of computers that work together and share information: “All of the printers are shared on the office network, so I can print documents from my computer anywhere in the building.” A “network” is also a group of radio stations or television stations that send out the same programs: “CNN is a very popular news network in the United States.” Finally, a “network” can be a system of transportation lines that are connected to each other and/or cross each other: “Does Mongolia have a good network of roads in the mountains?”

resolution

In this podcast, the word “resolution” means a solution or an end to a problem or argument: “The workers have been fighting for more money for the past year, but yesterday they finally reached a resolution with management.” “Resolution” can also refer to the quality of a digital picture: “We need to find a high-resolution photograph for the cover of the magazine.” Sometimes a “resolution” is a formal written decision made by an organization or a government agency: “The club passed a resolution deciding to accept 30 new members this year.” A “New Year’s resolution” is a decision made on December 31 to do something (or to not do something) during the following year: “Tanya’s New Year’s resolution was to call her mother once a week.”

Culture Note
In the United States, medical care is very expensive, so it is important to have health insurance. However, according to the “Census Bureau” (the U.S. government agency that keeps data or information about the number of Americans and their characteristics), in 2005 there were 46.6 million “uninsured Americans,” meaning U.S. citizens who don’t have health insurance. This was 15.9% of all U.S. citizens, and that number is growing.

The “main” (most important) reason for the high number of uninsured Americans is that health insurance is very expensive. Normally the employer pays all or some of the costs for the health insurance plan, but the “premiums” (the amount of money paid each year to have a health insurance plan) are increasing and employers cannot “afford” (to be able to pay) to pay the premiums anymore. When this happens, the employers ask the “employees” (the workers) to pay a larger percentage of the premiums, or they don’t offer health insurance plans at all.

Another reason that the number of uninsured Americans is growing is that there have been many changes in state and federal health insurance programs. Two government insurance plans that help people who can’t afford healthcare – “Medicaid” and the “State Children’s Health Insurance Program” – recently changed their rules about who is “eligible” (able to apply) for coverage. When these rules changed, some people lost their health insurance and weren’t able to afford an individual health insurance plan.

Many people are very worried about the growing number of uninsured Americans and have “proposed” (to present a new idea for doing something) creating a public health care plan that would be free for all U.S. citizens. However, others believe that this plan is too expensive and it is not likely that the U.S. will have “universal healthcare” (healthcare for everyone) in the near future.

Comprehension Answers
1 - a

2 - c