When shopping for a new individual health insurance plan, one of the main challenges people face is understanding the sea of acronyms and terminology. Here is a list to help understand some of the most basic individual health insurance terms.
Your premium is the amount you pay to the health insurance company each month (or quarter) to maintain your coverage. When you’re researching plans it’s usually the first cost you see and consider, but it’s important to also factor in the copayments, deductible, coinsurance, and out-of-pocket maximums, described below.
Your co-pay, or copayment, is a flat dollar amount you will pay your healthcare provider for a covered service. For example, you may have to pay a $30 copayment for each covered visit to a primary care doctor, and $10 for each generic prescription filled. Copayments vary from plan to plan and are sometimes different depending on the type of covered service you receive.
Your deductible is the amount you must pay for covered services before your health insurance begins to pay. Insurers apply and structure deductibles differently. For example, under one plan, a comprehensive deductible might apply to all services while another plan might have separate deductibles for covered services such as prescription drug coverage. Deductibles can significantly affect the price of your insurance premium. Typically, plans with lower deductibles offer more comprehensive coverage but have higher premium costs.
Coinsurance is a certain percent you must pay each benefit period after you have paid your deductible. This payment is for covered services only. You may still have to pay a copay.
For example, your plan might cover 80 percent of your medical bill. You will have to pay the other 20 percent. The 20 percent is the coinsurance.
5. Out-of-pocket Costs
Cost you must pay. These are your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered. Out-of-pocket costs vary by plan and each plan has a maximum out of pocket (MOOP) cost. Consult your plan for more information.
To read more or find other relevant insurance terms, check out this glossary of terms on medmutual.com.
Health insurance is imperative for any individual 26 years old and over, despite if he or she is currently healthy. The Affordable Care Act, which began in 2014, mandates that most Americans must purchase health insurance, even if they are questioning why they need coverage at all.
Similar to auto insurance, you just never know when an accident, or in this case unexpected news about your health, will arise. According to an article published by US News, “Most consumers want and value health insurance, but they can’t afford the coverage or have been shut out from the marketplace because they have pre-existing medical conditions,” (Olivero, Why Do You Need Health Insurance?). However, many people do not realize just how affordable health insurance is. The Affordable Care Act has implemented new affordable options so that you cannot be denied coverage for health insurance because of a pre-existing condition.
If you do not have health insurance, there are many risks you could be taking, such as paying a penalty, financial ruin, denied access to preventive care and primary care, denied follow-up care. There is a $95 tax for each adult, or 1 percent of annual income, if you do not have coverage. In 2016, this price will increase tremendously to $625 per adult, or 2.5 percent of annual income (whichever is greater). In the event that an onset or serious illness, such as cancer or diabetes, occurs, or if you happen to get into an accident like a car crash or snowboarding accident, the bills you will be required to pay will be extremely expensive without insurance. If you cannot pay the medical bills, you may need to file for personal bankruptcy.
Without access to preventive or primary care, another reason you should buy health insurance, you will be unable to detect health problems or diseases at an early state. Without access to mammograms, vaccinations, or prostate cancer screenings, you run the risk of not knowing whether or not you are developing a disease, which could otherwise be easily detected. According to US News:
“Policies also must provide a minimum standard of care known as essential health benefits in 10 categories: preventive and wellness services, ambulatory care services, emergency care, hospitalization, maternity and newborn care, pediatric care, mental health and substance use disorder services, prescriptions drugs and rehabilitative and habilitative services,” (Olivero, Why Do You Need Health Insurance?).
Without health insurance, you will not have access to any of these health benefits – so you must ask yourself, is it worth not being covered?
The answer is no. Even healthy, younger adults need preventive care, annual checkups, and chronic disease management. There is no guessing when you will need certain health care, or when your body will develop an illness or get into a skiing accident. These services offer a wide variety of treatment options for reasonable, affordable prices. Having good health is one of the most important things in your life. So don’t run the risk. Get covered.
If you are under the age of 30 and have hardship exemptions, you are most likely eligible to buy a catastrophic health plan, which protects you from very high medical costs. Many people buy this type of health insurance to protect them from worst-case scenarios that can happen at any given moment, such as a serious accident or illness.
Catastrophic health insurance plans require you to pay a certain amount of your medical costs, also known as deductibles. Once you have reached the deductible, the catastrophic plan will generally pay for the rest of your essential health benefits. In addition, most catastrophic plans, in comparison to comprehensive plans, have lower monthly premiums.
Three free primary care visits are covered by catastrophic plans each year, regardless if you reach your deductible or not. There are also many free preventive services that the plan covers, such as:
- Alcohol Misuse screening & counseling
- Aspirin Use (to prevent cardiovascular disease)
- Blood Pressure screening
- Cholesterol screening
- Depression screening
- Diabetes screening
- Diet counseling
- HIV screening
These preventative services are beneficial for your health in that they will detect certain illnesses at early stages, furthering you from harm. The sooner a disease is caught or prevented, the sooner you will have access to resources that will improve the state of your health so you can live the highest quality of life possible.
Another important fact to know about catastrophic health plans is that you will not be able to lower out-of-pocket-costs or earn premium tax credits based on your income. Healthcare.gov notes, “Regardless of your income, you pay the standard price for the catastrophic plan,” (About Catastrophic Health Insurance Plans).
In conclusion, you should learn if you qualify for a catastrophic health plan by filling out a Marketplace application, which will then give you an eligibility notice. For more information about obtaining a catastrophic plan, please visit Healthcare.gov’s article here.
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