Health Insurance can be difficult to understand. We want to help you understand every aspect of how health insurance works. Helping you find the right policy that protects you and your family is our mission. Health Insurance chosen right! Give us a call! 844-871-7850
A deductible is what you pay for covered medical expenses before the your insurance pays benefits.
Percentage that your policy will pay for covered services after your deductible has been met.
Fixed dollar amount you pay for covered services, such as lab work, prescriptions, or doctor visits. As a result, your deductible typically does not need to be met to have a copay.
The most you will pay out of pocket for covered services. For instance, after you pay the amount equivalent to your out-of-pocket maximum out of your pocket on deductibles, copayments, and coinsurance for in network services, therefore, your policy will pay 100% for costs of covered benefits for the remainder of the calendar year/term.
Insurance carrier scenario (your benefits)
Preferred Provider Organization
PPO does not limit you to what doctors or hospitals you can see. Generally, you will pay less for services within the plan’s network. However, you will pay an additional cost for for providers and services outside of the network.
Health Maintenance Organization
HMO limits coverage to the plan’s contracted network. Furthermore, out-of-network care is not covered except for emergencies.
Point of Service
Charges less if you use services within their contracted network. Additionally, POS plans require that you get a referral from your primary care physician to see a specialist.
Exclusive Provider Organization
Services are only covered if you go to doctors or hospitals within the plans network (except for emergencies). In addition, referrals may be required to see a specialist.
Affordable Care Act (ACA) is a health care reform law that was enacted in March of 2010 and aims to make the cost of health insurance more affordable to individuals. In addition, the ACA is commonly referred to as Obamacare and helps individuals with lower income, reduce monthly premiums with subsidies. Also, It is required that health insurance carriers have 10 Essential Health Benefits (EHB) to be deemed a Qualified Health Plan (QHP), such as, cover individuals that have pre-existing medical conditions.
Under the ACA, Major Medical plans must include 10 Essential Health Benefits. For example, this includes:
The Open Enrollment is November 1st through January 15th every year.
In addition, you can apply for coverage outside of the enrollment period if you have a Qualifying Life Event (QLE). For example, if you have a child, lose coverage or losing coverage, you will receive a Special Enrollment Period (SEP). Most importantly, please contact us if you feel that you should have a QLE so we can guide you.
*State-Based Marketplace (SBM) may differ
You may receive an Advanced Premium Tax Credit (APTC) if your household income is between 100% and 400% of the Federal Poverty Level (FPL). Therefore, you will pay a lower monthly cost for your health insurance, as low a $0 per month, if eligible. Additionally, you may receive this subsidy if your income is above $13,800 for an individual in states that have not expanded Medicaid or above $20,350 for states that have expanded Medicaid.
What you pay for medical expenses can be influenced by your Cost-Sharing Reduction (CSR), which has 3 levels that provide enhanced coverage if your income falls within a specific bracket on the FPL. As a result, the higher the CSR number is equivalent to lower deductibles, copayments, coinsurance, and out-of-pocket maximum which is only applicable to silver policies.
For example, those levels are CSR 94, CSR 87, and CSR 73.
Depending on the date you enroll can determine when your policy will effectuate. Consequently, if you enroll prior to the 15th of the month, your coverage will start on the 1st of the upcoming month, otherwise, it will effectuate on the 1st of that following month.
Apply either:
Catastrophic plans are not eligible to be subsidized for a lower monthly cost. Secondly, there are different eligibility requirements for these high deductible plans
For example, to be eligible:
Bronze plans have lower monthly premiums but higher deductibles. However, you may be able to be subsidized for these plans.
Meanwhile, you will pay 40% of the costs, while the insurance will pay 60%.
Silver plans have lower monthly premiums and are eligible for extra savings such as Cost-Sharing Reductions. Therefore, Silver plans can have the highest quality of coverage compared to the alternative tiers.
Meanwhile, you will pay 30% of the costs, while the insurance will pay 70%.
Gold plans have higher monthly premiums, however, provide more coverage.
It is certainly a good idea to verify that you don’t qualify for a Cost-Sharing Reduction with a Silver plan prior to selecting a Gold plan as a Silver plan may provide more enhanced coverage.
Meanwhile, you will pay 20% of the costs, while the insurance will pay 80%.
Platinum plans have the highest monthly premiums and often have low deductibles.
It is certainly a good idea to verify that you don’t qualify for a Cost-Sharing Reduction with a Silver plan prior to selecting a Platinum plan as a Silver plan may provide more enhanced coverage.
Meanwhile, you will pay 10% of the costs, while the insurance will pay 90%.
Report changes if you have a changes to tax filing status, income, if you move or even have new contact information. Therefore, use one of these three methods to report changes:
Healthcare.gov at times may require you verify your income, citizenship, or other verification requests. As a result, this may be required if something on your application is not matching up with consumer reporting agencies. Therefore, report changes using one of these three methods:
A major medical plan meets all the minimum essential health benefits required by the ACA, which include pre-existing conditions, ambulatory services, as well as mental health.
On-Exchange policies allow you to receive a subsidy through a state or federal exchange. Similarly, you will explore Off-Exchange policies if you will not receive a subsidy as this will provide additional coverage options.
Fixed indemnity insurance is a supplement insurance that offers first dollar coverage on medical expenses. On the other hand. under a major medical, or short-term plans, you are responsible for meeting your deductible before it pays on covered benefits. However, A fixed indemnity policy often offers immediate coverage at an affordable rate.
Additionally, pre-existing conditions are often excluded for the first 12-months of coverage.
A comprehensive medical plan is where you pair a medical policy, such as a policy through the Affordable Care Act, or a short term policy with a fixed indemnity policy.
As a result, the benefit of doing this is to meet your deductible and out-of-pocket maximum more quickly, ultimately saving you more money in the event something major happened to you causing significant medical bills. Additionally, if you have the right comprehensive medical plan, you could be covered at 100% in the event something happened that caused high medical bills.
Short-term medical insurance is a plan that will provide coverage similar to traditional coverage through short intervals. In addition, this is a great alternative for temporary coverage, however, can prove difficult to use with a high deductible if the plan is to have it long term.
Critical Illness Policies pay you a lump sum benefit in the event something major happened like a stroke, or a heart attack. Moreover, the policy will pay you a percentage of the maximum benefit depending on the catastrophic event that occurs.
An accident policy helps pay for medical costs incurred after an accident took place. Accident insurance quickly helps meet deductibles and out-of-pocket maximums given the benefits.
Teledoc allows for you to simply communicate with a doctor over the phone or video to be diagnosed, even prescribed medication in the event you had a non-emergency related medical condition.
Health Savings Account (HSA) allows you to pay for qualified medical fees on a pre-tax basis through through a savings account.
