Health Insurance 101

Healthcare in the United States is a for-profit system, where people who require medical care will be billed for the services rendered. In fact, the majority of providers will not see patients without having a health insurance policy. Accidents and sudden illnesses can result in tens of thousands of dollars in medical bills for something as simple as a slip and fall, or an acute medical condition like appendicitis or pneumonia. A major illness like cancer, heart-attack or stroke can result in hundreds of thousands of dollars in expenses. Health insurance is what limits your financial exposure to these risks throughout your lifetime.

Health insurance reduces your cost for routine care like Dr. visits, emergency/hospital care, medication, xrays, lab services, urgent care, chiropractic care and preventative services like physical examinations, mammograms, pap tests, colonoscopies, and osteoporosis screenings. In the event of a medical emergency, the insurance company will cover the majority of medical bills once the deductible has been met by the insured.

You can purchase health insurance through an Employer Benefit Plan, the Private Market working with a licensed advisor, and the State Marketplace, a.k.a. Obamacare.

A deductible is your buy-in amount before the insurance company takes over the majority / remainder of the remaining medical bills. Most plans have major medical deductibles ranging from $3,000-$10,000.

The Out of Pocket Maximum (OPM) on a policy is the most that an Insured would be responsible for in a 12 month period of time. Once your deductible is met, the Insurance Company will share the next set of charges with you up to a point, this is called Co-Insurance, and it’s typically 80/20, 70/30 or 60/40. Once a specific amount has been met, the insured has reached their OPM. At this point, the insurance co. would cover 100% of remaining expenses for the year. An example would be a $5,000 deductible with 80/20 coinsurance to $2,000. This equates to a $7,000 OPM for the year.

HMO - Health Maintenance Organization. This means the insurance is going to be accepted by a limited group of providers in your geographic area. They typically do not cover you out of state. Additionally, these plans require a referral from a primary care provider in order to see a specialist.

EPO - Exclusive Provider Organization. These networks are similar in size to an HMO where you’ve got to use the Drs/Hospitals that are in that network. However, you typically don’t need a referral in order to see a specialist.

PPO - Preferred Provider Organization. These insurance plans are widely accepted by the majority of providers, and give you the most freedom to see the Drs you want to see. These plans are common with large group employer and private market plans, and often give you access to Drs nationwide.

Depending on your situation, Obamacare can be a great fit for those with current or more major pre-existing conditions, those that receive income-based assistance, and those that require mental health or maternity coverage.

However, if you’re in good health, don’t receive a government subsidy, want large nationwide coverage, don’t want to have to shop/change health insurance every year, or just need something short term, then the private market is likely the better fit.

Ultimately, it depends on the plan as to how long the enrollment or application process can take. For individual or family coverage through the private market, it typically takes between 1-5 business days for coverage to begin and can take up to 30 days or more in certain instances. However, on most plans you can enroll in coverage and set the start date as far as 60 days out. This allows us to find the correct plan before you experience a lapse in coverage.

There are several different factors that determine group employer premium cost. It depends on group size, ages of employees, and if we are going the Guaranteed Issue or Individually Underwritten route.

Yes, dependents can stay on their parent’s plan until ages 24-26 depending on the state/plan. In most instances, you can easily add dependents/spouses to your existing policy.

Yes! Available on most plans, in most states.