Health insurance can be complicated; there is no doubt about that. While it is difficult to understand all the details of your health insurance policy, there are a few terms you should familiarize yourself with to make it easier to read and understand your policy. These basic terms will help you to shop for and make sense of your health coverage, so take a minute to learn and understand them.
Copay And Co-insurance
This is the amount you are expected to pay when you visit a doctor, go to urgent care, or to the emergency room. These terms are often used interchangeably, but they are a little different.
There are usually four different co-pay amounts for four separate types of doctor visits. The lowest co-pay is generally the one you pay to visit your regular doctor, pediatrician, or obstetrician. Often, a slightly higher co-pay is charged for a visit to a specialist. This can include specialties such as dermatology, ear, nose and throat (ENT) specialists, surgeons, and many more. Finally, there are usually two set co-pay amounts for either an urgent care or emergency room visit. Emergency room visits usually carry the highest co-pay amount.
Co-insurance usually refers to a percentage of the total cost that you are required to pay, especially for more unusual treatments and tests.
Much like your auto insurance, a health care deductible is the amount you are expected to pay before your benefits kick in. Co-insurance amounts do not usually count toward fulfilling your deductible requirements. In most cases, regular office visits also won’t be charged toward your deductible. Things like lab work, medical tests, and hospital visits are the types of costs that will count toward your deductible. Once you have paid out the full amount of the deductible, your policy will cover everything else at the set amount.
If you have other family members on your policy, you may have two deductible amounts-one per individual and one per family. Once the family limit is met, no further deductible payments are required.
Out Of Pocket Limit
Most insurance policies carry a yearly out of pocket limit; this means that there is a limited amount of money you will have to pay out of pocket in that year. After this limit is reached for the year, insurance will cover the rest of your medical care in full. This limit protects you in the event of a serious illness or injury that results in a lot of medical bills.
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Health insurance has changed dramatically in the last 3 years. Before The Affordable Care Act of 2010 (ACA) aka Obamacare, people who had pre-existing conditions would not be eligible or be discriminated in premium hikes due to their health. Since the ACA, no insurer could charge or deny you coverage based on your current health or pre-existing condition.
The Affordable Care Act mandated plans both inside and outside of the Health Insurance Marketplace to offer 10 Essential Health Benefits to everyone without discrimination; emergency services, hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative services; lab services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Today, families and individuals can qualify based on family size and income to help them with the cost of the monthly plan premiums called a “tax credit”.
There are policies available for those who do not wish to participate in the Marketplace, those plans still cover the 10 Essential Health Benefits. When someone chooses not to enroll into a Marketplace plan, they will not have the option to see if they qualify for a tax credit to help them with the monthly plan premiums. Being enrolled into these plans will keep you from being penalized for not having health insurance.
Dental and Vision plans are not included for adults in the health plans. They are offered separately and there is a wide range of plans to choose from to fit your budget.
When you become eligible for Medicare, whether it’s be because you turned 65 or have been on disability for 24 months, we also offer a wide range of Medicare Advantage Plans and Supplemental Plans as well.
Starting a family is a major undertaking and will change everything about your life. Now that you are responsible for the health and wellbeing of your children, having good health insurance takes on a whole new meaning. When you are single, it is easy to shrug off the importance of health coverage. Now that you have a family, your policy will need to offer a whole lot more.
Maternity And Beyond
Before you need health coverage for your child, you will need coverage for the pregnancy. The nine months prior to birth and the delivery itself will put a big strain on your wallet if you don’t have good coverage. That’s why it’s important to plan ahead for starting a family. Good prenatal care will give your child the best start in life, so be sure you are covered for it.
Health Care For Children
In the first few years of life your child will need regular well visits with a pediatrician as well as many vaccinations for protection from dangerous childhood diseases. In fact, it may seem you are constantly headed to the doctor’s office with your child, and that’s just when they are healthy. With their immature immune systems, children are susceptible to all kinds of illness, from colds to ear infections and more. Expect to visit the pediatrician several times a year for illness. Because children are also clumsy and impulsive, especially in the toddler and preschool years, they are also prone to accidents that may send you to the emergency room.
Your health plan has to be up to the task of keeping your child covered through all of the bumps, bruises, fevers, and mistakenly swallowed items that are such common parts of growing up.
What To Look For
When choosing a health plan for your family, look first for good maternity coverage, unless you have already had children and don’t plan to have more. Next, you will want something with low co-pays for office visits, since you will probably have a good number of those. Also check on what you would be expected to pay out of pocket for an emergency room visit. You will usually be responsible for a co-pay unless the child is admitted to the hospital. In that case, a different sort of co-insurance may apply. Check what percentage of emergency room bills and hospitalization is covered under the plan.
Family health plans carrying deductibles generally have a per person deductible as well as a family deductible that has to be met. These are good numbers to know when comparing health plans.
If you are switching health plans and would like to keep your current pediatrician, you will want to look for a PPO
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