Understanding How Health Insurance Works
Understanding How Health Insurance Works
How Does Health Insurance Work? By HealthPlans
1. You have an health issue.
2. Visit your doctor.
3. Your doctors bills your insurance provider.
4. Your insurance provider reimburses your doctor.
Key Health Insurance Terms
40% of uninsured Americans don't understand key health insurance terms.
Deductible
The amount you pay each year to cover eligible medical expenses before your insurance policy starts paying. After you pay your deductible, you only pay a copayment or coinsurance.
Co-Insurance
A percentage that you pay to share the cost of covered services with your insurance provider after your deductible has been paid. For example, if the co-insurance is 20%, the insurance company pays 80% of the claim and you pay 20%.
Co-Pay
A flat fee for certain medical expenses; your insurance company pays the rest.
Premium
The amount you pay for your health plan every month to purchase health coverage.
Out-Of-Pocket-Max
The max amount you will pay during a year for coverage. It includes deductibles, copayments, and coinsurance. Beyond this amount, the insurance company covers 100% of eligible medical expenses for the remainder of the year.
Essential Benefits
All plans include access to : ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services including behavioral health services, prescription drugs, rehabilitative services, laboratory services, preventive and wellness services, chronic disease management, pediatric services including oral and vision care.
Out-Of-Pocket Max
Your medical costs include all deductibles, co-insurances, and co-pays that do not go over your limits.
Your insurance company will be responsible for all medical costs after your limits are met.
How Much Will I Pay?
Plans are categorized into 5 levels. Your level determines how your medical bill is divided between you and your insurer.
Subsidy Eligibility
27 million+ uninsured Americans are eligible for financial assistance.
53% of uninsured Americans don't know that financial help is available
Eligibility Takes into Consideration:
Household size and adjusted annual income range.
If your household falls into these income ranges, you might be eligible for subsidies:
Household Size
Other Qualifications for Subsidy:
Legal US resident, not incarcerated, and no affordable minimum essential coverage.
Health Insurance Basic Plan Types
HMO
Most restrictive. Requires you to choose a Primary Care Physician (PCP) from their provider networks. If you go out of network, you have to pay all medical costs.
PPO
Most flexible. You need not stay in-network for health care and do not have to use a PCP. You can go out of network for care, but you will receive less coverage.
POS
POS plans are hybrids of HMO and PPO plans. You must choose a PCP, can go out of network and still receive insurance coverage. Out-of-pocket expenses are substantially higher if you do not get referrals for non-network care.
EPO
EPO plans are hybrids of HMO and PPO plans. You must choose a PCP, can go out of network and still receive insurance coverage. Out-of-pocket expenses are substantially higher if you do not get referrals for non-network care.
Act Now
Having health insurance protects you
from health and financial risks:
Illness
Health insurance covers essential health benefits critical to maintaining your health and treating illness.
Bills
Health insurance protects you from high medical costs. 62% of personal bankruptcies in America are caused by medical bills.
High Costs
You pay less for covered in-network health care, even before you meet your deductible.
Penalties
If you have qualifying coverage, you don't have to pay any tax penalties.
Checkups
You get free preventive care, like vaccines, screenings, and some check-ups, even before you meet your deductible,
Comparing
Comparing health insurance plans and finding the coverage that's right for you can be a complicated and difficult process, but it doesn't have to be.
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