Medical insurance plans #shop #insurance

#medical insurance plans #Glossary of Terms We’ve translated some of..

Medical insurance plans #shop #insurance

#medical insurance plans
#

Glossary of Terms

We’ve translated some of the confusing terminology around health insurance into plain English so you can better understand your health plan options.

Health Insurance Terms:

Your share of the health care service cost once you’ve met your deductible (if you have one). For example, if your bill is $100, and your coinsurance is 20%, you will pay $20 for your medical services if you have already met your deductible.

A fixed amount of money that you may need to pay for a covered health care service or supply. For example, your health plan may require a $15 copay for an office visit or generic prescription, after which the plan will pay the remainder of the cost.

The amount of money that you may need to pay out-of-pocket for health care services before your health insurance plan begins to help with payments. For example, if your deductible is $100, your plan won’t pay for anything until you’ve paid the $100 deductible.

A set of health care services that must be covered by plans in the Health Insurance Marketplace. These services include emergency services, hospitalization, maternity and newborn care, mental health, prescription drugs, preventive and wellness services, pediatric services, and more.

A group of doctors, hospitals, and other health care providers that a health insurance plan has partnered with to provide care to the plan’s members. These providers are called “network providers” or “in-network providers.” You can find out if a provider is in-network by checking with your health insurance plan.

The most you’ll pay in a policy period (usually one year), before your plan starts to pay 100% of the covered Essential Health Benefits you receive. This limit must include Deductibles, Coinsurance, and Co-payments, but does not typically count Premiums, toward your out of pocket maximum. The maximum out-of-pocket cost limit in 2016 can be no more than $6,850 for an individual plan and $13,700 for a family plan.

Doctors, hospitals, and other health care providers who have not partnered with your health insurance plan to provide care to the plan’s members. You may have to pay more for services from an out-of-network provider.

Health care services focused on keeping you healthy before you may become sick. These include routine check-ups, patient counseling, screening tests, and immunizations. Plans must offer these services at no cost to you when the services are provided by in-network doctors. This means they can’t charge a Copayment or Coinsurance, even if you haven’t met your deductible for the year.

Plan Types

You’ll notice many types of plans when you’re trying to find the right plan for yourself and your family. We’ve explained what it all means below.

Explaining Plans by Metal Level

Depending on how many plans are offered in your area, you may find plans of all or any of these types at each metal level – Bronze, Silver, Gold, and Platinum. There are different types of Catastrophic plans too.

Bronze:

Bronze plans tend to have the lowest monthly premiums. Bronze plans must cover an average of 60% of all your covered out-of-pocket costs while you are responsible for the remaining 40%. Bronze plans qualify for Tax Credits.

Silver:

Silver plans tend to have the second lowest monthly premiums. Silver plans must cover an average of 70% of all your covered out-of-pocket costs while you are responsible for the remaining 30%. Silver plans qualify for both Tax Credits and Cost Sharing subsidies. These are the only types of plans to qualify for cost sharing reduction.

Gold:

Gold plans tend to have the second highest monthly premiums. Gold plans must cover an average of 80% of all your covered out-of-pocket costs while you are responsible for the remaining 20%. Gold plans qualify for Tax Credits.

Platinum:

Platinum plans tend to have the highest monthly premiums. Platinum plans must cover an average of 90% of all your covered out-of-pocket costs while you are responsible for the remaining 10%. Platinum plans qualify for Tax Credits.

Catastrophic coverage:

Catastrophic health plans are the least expensive plans you can get that count as minimum essential benefits. If you are under 30 or obtained a “hardship exemption” you qualify for high deductible, low premium, catastrophic plans. These have extremely high out-of-pocket costs.

Explaining Plans by Network Type

You’ll have to pay more for health care services for providers outside your plan’s network depending on the type of plan. Some examples of these types of plans are:

Exclusive Provider Organization (EPO):

These types of plans cover care provided by doctors, specialists, or hospitals exclusive to the plan’s network (except in an emergency). As a member of this plan, you may not need a referral from your primary care doctor to see a specialist in the plan’s network.

Health Maintenance Organization (HMO):

These types of plans limit coverage to care from only the doctors in the plan’s network. It generally won’t cover out-of-network care except in an emergency. HMOs often require members to get a referral from their primary care physician in order to see a specialist.

Point of Service (POS):

These types of plans allow you to pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. Members can still seek out-of-network care, but will typically pay more. POS plans require you to get a referral from your primary care doctor in order to see a specialist.

Preferred Provider Organization (PPO):

These types of plans allow you to pay less if you use providers in the plan’s network. However, you can use doctors, hospitals, and providers outside of the network without a referral but potentially at higher costs.

Financial Help

We’ve translated some of the confusing terminology around health insurance into plain English so you can better understand your health plan options.

Cost Sharing Reduction (CSR):

Cost Sharing Reduction provides a discount that lowers the amount you have to pay for deductibles, coinsurance, and copayments. This is based on your income and can only be applied to Silver plans.

Financial assistance or Savings:

There may be ways for those with low or middle incomes to get help paying for their health insurance by signing up for a plan through the Health Insurance Marketplace. If you qualify for financial assistance, the government will pay a portion of your health insurance premiums directly to your health insurance company every month. This will lower the amount of money you have to pay for your health insurance premium every month.

Health insurance requirement or Individual mandate:

As part of the new health care law, most Americans will need to have health insurance. If you do not have health insurance, you may have to pay a fine. You won’t have to pay a fine if you have a very low income and coverage is unaffordable for you, or for other reasons including your religious beliefs. You can also apply for a waiver asking not to pay a fine if you aren’t automatically exempt.

Open enrollment period:

The period of time when you can sign up for health coverage through the Health Insurance Marketplace. The next open enrollment period is from November 1, 2015 to January 31, 2016.

Premium tax credit or Subsidy:

A type of financial help that you may qualify for that reduces your monthly payment (or premium) as soon as your coverage begins. For example, if your premium is $200, and you qualify for a $180 a month premium tax credit, you will pay $20 a month for your insurance plan. The amount of your premium tax credit is based on your estimated yearly income.






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