Health Insurance Terms
What do all these health plan terms mean? We are here to help them make sense!
INDIVIDUAL AND FAMILY INSURANCE PLANS
It is important to have the right health insurance plan that can protect you and your family from huge amounts of medical bills. We can assist you, most especially if this is your first time researching health insurance. We have been helping individuals and families find affordable health insurance plans based on their unique needs and budgets since 2006. We can also help you apply for financial assistance you may qualify for through the Health Insurance Marketplace to help reduce your monthly health insurance costs.
What are individual and family health insurance?
People who aren’t currently covered by either a job-based policy or a government program like Medicare or Medicaid can purchase individual health insurance policies.
You’ll have access to less expensive medical treatment when you need it if you have an individual or family insurance plan, such as a $20 copay rather than a whole $100 payment.
Additionally, you’ll feel more secure knowing that you’ll be protected in the event of a serious illness or injury; for instance, your medical expenses might be limited to $6,000 even if you get a $200,000 procedure.
Types of Health Insurance Plans
- Health Maintenance Organization (HMO)
HMO plans offer health care services through a network of providers who agree to lower rates or provide services only to its members. With this health plan, you have a primary care doctor who must be in your HMO network. If you need a specialists, they must refer you. If you see a doctor outside of this network, you will have to pay the full amount. Kaiser Permanente is a well-known example of an HMO plan.
- Preferred Provider Organization (PPO)
PPO plans allow you to see any in-network health care provider without a referral from your primary care physician. You may see out-of-network providers but you will pay a higher amount. PacificSource is one of the PPO plan options in the market.
- Exclusive Provider Organization (EPO)
Like PPO, EPO plans let you see health care providers without referral from primary care, however, you must visit doctors and hospitals within the EPO network. There are no out-of-pocket benefits, so you will pay the full amount if you go to a provider outside of your plan network. Providence Health Plan is known for its EPO plan.
In essence, these plans don’t differ just on health plan cost but also the size of the plan network, ability to see specialist and coverage for out-of-network services.
- Premium – The amount you pay your health insurance company every month
- Deductibles – The amount you pay for health care services before your health insurance company starts to pay. For example, a plan with a $2,500 deductible means you pay the first $2,500, and after you pay that amount of medical bills, you usually pay just a copay or coinsurance percentage while the rest is paid by your insurance company
- Co-pay – A small amount you pay each time you use a specific healthcare service (this payment does NOT go toward meeting your deductible)
- Co-insurance – The amount you pay for healthcare expenses after your deductible is met. For example, if your plan has a $1,000 deductible and you have spent $1,000 on medical bills, your insurance will now start paying a predefined percentage of your costs and the remaining percentage is the coinsurance you are responsible to pay
- Out of Pocket Cost – The highest amount you have to pay for covered health care services in a plan year. Once you meet your out-of-pocket cost, your health insurance company pays 100% of the cost of covered benefits.
How to Get Health Coverage?
You can get health insurance through:
- a group insurance policy through your employer, that of your spouse or partner, or both
- If you are under 26 years old, your parents’ insurance policy
- a plan you buy on your own, either directly from an insurer or on the Health Insurance Marketplace.
- government initiatives like Medicare and Medicaid
- Health Insurance Program for Children (CHIP)
- TRICARE or the Veterans Health Administration for Military members
- temporary continuation of employer coverage provided by your former employer under the Consolidated Omnibus Budget Reconciliation Act (COBRA)
Choosing a Health Insurance Plan
These questions may help:
- Am I free to choose any physician, facility, clinic, or pharmacy?
- Do specialists like dentists and eye doctors fall under this policy?
- Does the plan cover exceptional circumstances or medical situations like pregnancy, psychiatric treatment, or physical therapy?
- Does the plan cover care in nursing homes or at home?
- Will the plan cover every drug that my doctor might recommend?
- What are the deductibles? Before your insurance provider will start paying claims, you must pay this amount each year.
- Are there any co-payments? This is the sum of money you have to pay every time you get medical care or a prescription.
- How should a bill or service be handled if there is a dispute?
Let's Find the Right Plan for You
*By completing this form, you agree that an authorized representative or licensed insurance agent may contact you by phone,email,text, mail or face to face to answer your questions or provide additional information about your Medicare plan options. Not affiliated or endorsed by Medicare or any state or federal governmental agency.