Health insurance plans, one of the important steps before we determine what kind of insurance that we will take.
Don't confuse your friends, hopefully this little writing can be a reverensi for you.
When choosing among different health care plans, you'll need to read the fine print and ask lots of questions, such as:
- Do I have the right to go to any doctor, hospital, clinic or pharmacy I choose?
- Are specialists such as eye doctors and dentists covered?
- Does the plan cover special conditions or treatments such as pregnancy, psychiatric care and physical therapy?
- Does the plan cover home care or nursing home care?
- Will the plan cover all medications my physician might prescribe?
- What are the deductibles? Are there any co-payments?
- What is the most I will have to pay out of my own pocket to cover expenses?
- If there is a dispute about a bill or service, how is it handled? In some plans, you may be required to have a third-party decide how to settle the problem.
There are several important things to consider when you compare plans.
- Plan category: There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic. Plans in these categories differ based on how you and the plan share the costs of your care. The categories have nothing to do with the amount or quality of care you get.
- Monthly premiums: This is the amount you pay your insurance company for your plan, usually monthly, whether you use medical services or not.
- Out-of-pocket costs: These include the costs you pay before your insurance begins to pay its share (your deductible, copayments, coinsurance, and your out-of-pocket maximum).
- Type of insurance plan and provider network: Some types of plans allow you to see almost any doctor or health care facility. Others limit your choices to a network of doctors and facilities, or require you to pay more if you use providers outside the network.
- Benefits: All plans sold through the Marketplace provide the same essential health benefits and cover pre-existing conditions and offer free preventive services. But some plans offer additional benefits.
The rules for insurance provided by large employers are a little different but the vast majority them will cover the same set of benefits. To make sure, ask your employer for the Summary of Benefits and Coverage, a standard form that will state exactly what the plan covers and doesn't cover.
It's important to know, though that some older plans may not cover this whole list of services. These are plans sold to individuals or small business (with up to 100 employees) that started before the new health reform law took full effect in 2014. Under certain circumstances these plans can be renewed even though they don't have all the consumer protections available with newer plans. If you have such a plan your insurance company will send you a notice about it before the annual renewal date. Then you can consider whether to keep it or to switch to a new plan.
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It's important to know, though that some older plans may not cover this whole list of services. These are plans sold to individuals or small business (with up to 100 employees) that started before the new health reform law took full effect in 2014. Under certain circumstances these plans can be renewed even though they don't have all the consumer protections available with newer plans. If you have such a plan your insurance company will send you a notice about it before the annual renewal date. Then you can consider whether to keep it or to switch to a new plan.
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You pay for health insurance in two ways:
The monthly premium that you pay to purchase your plan.
The out-of-pocket expenses you pay when you receive medical care. Those are some combination of deductibles, coinsurance, and copays.
In general, if you pay a higher premium upfront, you will pay less when you receive medical care, and vice versa.
If you purchase coverage through your state's Health Insurance Marketplace, you may be eligible for income-based subsidies that lower the cost of your premium and in some cases your out-of-pocket expenses.
Which of those plans is right for you depends on your health and your financial situation:
If you already know you have an expensive medical condition, consider a plan with a higher premium that covers more of your costs.
The monthly premium that you pay to purchase your plan.
The out-of-pocket expenses you pay when you receive medical care. Those are some combination of deductibles, coinsurance, and copays.
In general, if you pay a higher premium upfront, you will pay less when you receive medical care, and vice versa.
If you purchase coverage through your state's Health Insurance Marketplace, you may be eligible for income-based subsidies that lower the cost of your premium and in some cases your out-of-pocket expenses.
Which of those plans is right for you depends on your health and your financial situation:
If you already know you have an expensive medical condition, consider a plan with a higher premium that covers more of your costs.
If you are generally healthy you might come out ahead paying a lower premium and a bigger share of your health costs, because those costs are most likely not going to be that high. Of course, you need to be prepared to pay more if you do unexpectedly become sick or injured.
When you’re choosing a health insurance plan, you’ll want to look at more than the premiums and deductibles to evaluate plan options. Take a look at the co-insurance amount, too, and then decide which deductible, premium and co-insurance mix is the best option for you.
There are many factors to consider when choosing a health plan. Think about both your medical and financial needs – from coverage options to monthly premiums , to co-payments and deductibles . Consider your family situation, your family’s anticipated health care needs and available plan options.
It's a good idea to assess your needs and identify your priorities so you know what to look for in a plan. Consider costs, coverage, benefits, doctor flexibility and plan limitations to help you decide which plan is right for you.Once you know what plan options are available, you can evaluate plan options to determine which one is right for your situation. Review your plan materials – such as brochures, benefit summaries and websites – to find the details that will help you decide.
The terms “cost sharing” or “out-of-pocket costs” refer to the proportion of your medical bills you will be responsible for paying when you actually receive health care. Cost sharing does not include your monthly premium.
If you buy insurance through your state marketplace, you’ll be able to see and compare the cost-sharing structure of plans before you buy. If you get insurance through a job, the information will be on the Summary of Benefits and Coverage form.
DEDUCTIBLE. The amount you pay every year before the insurance company starts paying its share of the costs.
COPAY. A fixed dollar amount you pay for certain types of care.
COINSURANCE. The percentage of the cost of your medical care that you have to pay.
OUT-OF-POCKET LIMIT. The most cost-sharing you will ever have to pay in a year.
You may be able to pair your health plan with a Health Savings Account (HSA) that you can use to pay for qualified medical expenses. An HSA must be paired with a qualified high-deductible health plan. It allows you to put away a limited amount of pre-tax dollars to pay for eligible medical expenses. An HSA is yours to keep even if you change employers or benefits.
Every health insurance plan has a network of providers—doctors, hospitals, laboratories, imaging centers, and pharmacies that have signed contracts with the insurance company agreeing to provide their services to plan members at a specific price.
If a doctor is not in your plan's network, the insurance company may not cover the bill, or may require you to pay a much higher share of the cost. So if you have doctors you want to continue to see, you will want them to be in the plan's network.
Some state Health Insurance Marketplaces, including those operated through the federal HealthCare.gov site, have links to provider directories that you can see before you buy. But the directories are not standardized and may be hard to use or out of date. Moreover, to keep costs down, many of the plans sold through the state Health Insurance Marketplaces have smaller networks than you may be used to. That is why you should check and double-check with the health plan and your doctor's billing office to make sure your desired providers are in the network of the plan you are considering.
If you are given a choice of insurance through a job, you can obtain provider lists from participating insurance companies, or from the company’s employee benefits department. You can use our hospital Ratings (subscription required) to research the quality of the hospitals in your network.
Every health insurance plan has a network of providers—doctors, hospitals, laboratories, imaging centers, and pharmacies that have signed contracts with the insurance company agreeing to provide their services to plan members at a specific price.
If a doctor is not in your plan's network, the insurance company may not cover the bill, or may require you to pay a much higher share of the cost. So if you have doctors you want to continue to see, you will want them to be in the plan's network.
Some state Health Insurance Marketplaces, including those operated through the federal HealthCare.gov site, have links to provider directories that you can see before you buy. But the directories are not standardized and may be hard to use or out of date. Moreover, to keep costs down, many of the plans sold through the state Health Insurance Marketplaces have smaller networks than you may be used to. That is why you should check and double-check with the health plan and your doctor's billing office to make sure your desired providers are in the network of the plan you are considering.
If you are given a choice of insurance through a job, you can obtain provider lists from participating insurance companies, or from the company’s employee benefits department. You can use our hospital Ratings (subscription required) to research the quality of the hospitals in your network.
By now, you should (hopefully) have your plan options narrowed down to just a few. To narrow down further, go back to that summary of benefits to see if there are any plans that cover a wider scope of services. Some may have better coverage for things like physical therapy or mental health care, while others might have better emergency coverage. By skipping this quick but important step, you could miss out on a plan that’s much better tailored to you and your family.
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