What is the Affordable Care Act?
The Affordable Care Act, also known as the health care reform law, was passed by our government in 2010. The law makes health insurance available to more people, so more people will be able to get the care they need.
What if I have an ongoing illness? Can I still get health insurance?
Yes. You cannot be denied health insurance coverage because of your medical history. Everyone who applies for health coverage is guaranteed acceptance for coverage. You can’t be turned down. You may qualify for financial assistance to lower the cost of your monthly premium and the cost of your medical care.
What is the difference between an HMO and a PPO?
In a health maintenance organization (HMO), you receive all or most of your healthcare from a network provider. HMOs require that you select a primary care physician who is responsible for managing and coordinating all of your healthcare.
A preferred provider organization (PPO) is a health plan that has contracts with a network of “preferred providers” from which you can choose. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. If you receive your care from a doctor in the preferred network, you will be responsible for only your annual deductible and a co-payment for your visit. If you receive health services from a doctor or hospital that is not in the preferred network (known as going “out of network”), you will pay a higher amount. When obtaining out-of-network care, you pay the doctor directly and file a claim with the plan for reimbursement
What’s the difference between a PPO and an HDHP?
PPO refers to the network structure of a plan, whereas HDHP refers to its pay structure. A high deductible health plan simply works differently than more traditional plans in that there are no copays — you pay everything out-of-pocket until you reach your deductible. After that, the plans co-insurance kicks-in, and the insurer picks up a percentage of the bills until you reach your out-of-pocket maximum.
What is co-insurance and how does it work?
The percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible. Let’s say your health insurance plan’s allowed amount for an office visit is $100 and your coinsurance is 20%. If you’ve paid your deductible: You pay 20% of $100, or $20.
What is telemedicine?
Telemedicine is a service included in some insurance plans that allows policyholders to speak to doctors on the phone (without a copay) instead of making an appointment with a primary care physician. Medicine can be called into your local pharmacy, if a prescription is necessary.
What’s an embedded deductible?
The term ‘embedded deductible’ means that an individual doesn’t have to meet the family deductible in order for co-insurance to kick in. Once a person covered under a family plan reaches the individual deductible, all covered expenses for that individual will be paid at the co-insurance amount even when the family deductible has not been satisfied. Once another person or a combination of persons meet the remaining portion, the family deductible would be considered satisfied.
What’s an embedded out-of-pocket maximum?
An embedded out-of-pocket maximum works in the same way an embedded deductible works. Once a person covered under a family plan reaches the individual out-of-pocket maximum, all covered expenses for that individual will be paid at 100% even when the family out-of-pocket maximum has not been satisfied. Once another person or a combination of persons meet the remaining portion, the family out-of-pocket maximum would be considered satisfied.
How do deductibles and out-of-pocket maximums work?
Your deductible is the amount you must contribute prior to your insurance kicking in. In the case of high deductible health plans, everything comes out of your pocket until you hit this number, at which point co-insurance kicks in until you reach your out-of-pocket maximum. In the case of more traditional health plans, other services may be covered beforehand (with a copay), such as primary care or specialist visits. The out-of-pocket maximum is the highest amount you can be expected to pay in out-of-pocket expenses in a given year, including your deductible and co-insurance.