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Have a question about health insurance?

Health insurance can be confusing, but GetCovered is here to answer questions about health insurance that you may have!

See the answers for common questions below.

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What is out-of-pocket maximum?

Out-of-pocket maximum is the most you have to pay for covered health services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network careIn-network care is when a health provider has a signed agreement with your health insurance company to provide care for plan members at a certain rate and services, your health plan will pay 100% of the cost of covered benefits.

 

 

The out-of-pocket limit doesn't include:

  • Your monthly premiums
  • Anything you spend for services your plan doesn't cover
  • Out-of-network care and services
  • Costs above the allowed amount for a service that a provider may charge

What is coinsurance?

Coinsurance is a way for health insurers to split costs with you. It is based on a percentage of covered health care services after you have met your deductible. For example, if you have 30% coinsurance and your doctor’s visit is $150:

  • If you haven’t met your deductible: you’ll pay $150 for the visit
  • If you have met your deductible: you’ll pay 30% of $150 ($45). The insurance company will pay the rest.

 

The amount you pay for copay or coinsurance is decided by your health insurer and pricing varies. Your copay or coinsurance amount will be listed in your insurance documents or on your ID card.

What is a premium?

A premium is how much you pay a health insurance company each month to use a health insurance plan.

Exploring Plan Types

What is Medicare?

Medicare is a federal health insurance program that provides free or very discounted health care to eligible people who enroll. You may be eligible for Medicare if you:

  • are 65 years old or older (even if you are still working), or
  • Are any age and disabled, or
  • Have End-stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)

 

There are different parts of Medicare to help cover specific services:

  • Medicare Part A covers stays in the hospital, nursing facility, hospice care, and some home health care
  • Medicare Part B covers certain doctors’ services, outpatient care, medical supplies and preventive services
  • Medicare Part D covers the cost of prescription drugs (including shots and vaccines)

 

Most people do not pay a monthly premium for Part A coverage. Everyone will pay a monthly premium for Part B coverage.
 

You can either opt in to Part D coverage (called an original Medicare plan), or choose an all-in-one alternative that bundles Part A, Part B, Part D coverage (also called Medicare Advantage Plan).

 

To learn more about Medicare, visit www.medicare.gov

What is Medicaid?

Medicaid is a joint federal and state health insurance program for eligible low-income:

 

  • Adults
  • Children
  • Pregnant women
  • Elderly adults
  • People with disabilities

 

How Medicaid is administered varies by state. To learn more, visit www.medicaid.gov.

What is dual eligibility?

Dual eligibility is when an individual qualifies for both Medicare and Medicaid.  If an individual meets the federal requirements for Medicare and the state requirements for Medicaid, then they are dual eligible.

For example, if you are over the age of 65 and your income is below the federal poverty line, then you may qualifty as dual eligible.

What are the requirements to be eligible for ACA subsidies?

The Affordable Care Act (ACA), also known as Obamacare, is a health reform law enacted in 2010 with the goal of making affordable health insurance available to more people. 

In order to qualify for subsidies, you must meet the following criteria: 

  • You are currently living in the United States
  • You are a US citizen or legal resident
  • You are not currently incarcerated
  • Your household income falls within a certain range

What are the differences between bronze, silver, gold, and platinum health plans?

These metal tiers were set up through the Affordable Care Act in support of individual packages. Each tier covers a certain percentage of health care costs.

 

Bronze plan

  • Lowest monthly premiumsA premium is how much you pay a health insurance company each month to access a health insurance plan.
  • Highest out-of-pocket costs (copay/coinsurance)A copay is a set rate you pay for prescriptions, doctor visits, and other types of care. Coinsurance is the percentage of costs you pay after you've met your deductible.
  • High deductiblesA deductible is the amount you pay for eligible health care services (e.g., doctor and hospital visits, medical procedures) each year before your health insurance pays its portion of the cost.
  • This is usually best for people who are very healthy but want coverage for emergency medical situations. Wellness visits are covered.

 

Silver plan

  • Moderate monthly premiumsA premium is how much you pay a health insurance company each month to access a health insurance plan.
  • Moderate out-of-pocket costs (copay/coinsurance)A copay is a set rate you pay for prescriptions, doctor visits, and other types of care. Coinsurance is the percentage of costs you pay after you've met your deductible.
  • Moderate deductiblesA deductible is the amount you pay for eligible health care services (e.g., doctor and hospital visits, medical procedures) each year before your health insurance pays its portion of the cost.
  • This is often a good plan for an individual or family in need of only routine care.

 

Gold plan

  • High monthly premiumsA premium is how much you pay a health insurance company each month to access a health insurance plan.
  • Low out-of-pocket costs (copay/coinsurance)A copay is a set rate you pay for prescriptions, doctor visits, and other types of care. Coinsurance is the percentage of costs you pay after you've met your deductible.
  • Low deductiblesA deductible is the amount you pay for eligible health care services (e.g., doctor and hospital visits, medical procedures) each year before your health insurance pays its portion of the cost.
  • This may be a great plan for someone who needs routine care on a regular basis and prefers to pay a little more each month as opposed to paying more for each visit.


Platinum plan

  • Highest monthly premiumsA premium is how much you pay a health insurance company each month to access a health insurance plan.
  • Lowest out-of-pocket costs (copay/coinsurance) A copay is a set rate you pay for prescriptions, doctor visits, and other types of care. Coinsurance is the percentage of costs you pay after you've met your deductible.
  • Very low deductiblesA deductible is the amount you pay for eligible health care services (e.g., doctor and hospital visits, medical procedures) each year before your health insurance pays its portion of the cost.
  • This may be a great plan for someone who regularly needs care and can pay higher monthly premiums while having most if not all costs covered.

What types of health insurance coverage options are available to me?

There are many different factors that define which health insurance coverage option is best. These factors include:

  • Job status
  • Income
  • Age
  • Current health status

 

For example, an individual who has lost their health insurance coverage due to the loss of a job may qualify for Consolidated Omnibus Budget Reconciliation Act (COBRA).

An individual over the age of 65 or under the age of 65 with certain disabilities may qualify for Medicare.

 

Click here to find out what health coverage options could be available to you.

What is a PPO Plan?

A PPO plan is a plan that provides access to a preferred provider organization. With these private plans, individuals may pay less if they use doctors, hospitals, and providers that belong to the network.

Individuals can use doctors, hospitals, and providers outside of the network, but they may pay more out of pocket.

What is a POS Plan?

A POS plan is a point-of-service plan. With these private plans, individuals may pay less if they use doctors, hospitals, and providers that belong to the network.

Individuals must get a referral from their primary doctor if they need to see a specialist.

What is an EPO Plan?

An EPO plan is plan that provides access to an exclusive provider organization. With this managed care plan, individual care is covered if an individual goes to the doctors, specialists, or hospitals in the network (except in an emergency).

What is a high-deductible health plan?

A high-deductible health plan is a private plan with a higher deductibleA deductible is the amount you pay for eligible health care services (e.g., doctor and hospital visits, medical procedures) each year before your health insurance pays its portion of the cost.. The monthly premium for these plans is often lower, but an individual pays more for healthcare costs themselves before the insurance company starts to pay.

I have trouble paying for prescription drugs, where can I get insurance from?

Here are resources that may make things easier for you:

 
 
 
 
 

 

Health Plans 101

Is it important to have health insurance?

Health insurance is important even if you are healthy. No one plans to get sick or hurt. With health insurance you are covered should any costly medical emergency happen. Having health insurance also will help you stay healthy with preventive care and early intervention.

Is there a penalty for not having health insurance?

There is no longer a federal penalty for not having health insurance. This penalty was eliminated at the end of 2018.

 

However, some states have their own individual mandates and penalties:

  • Massachusetts
  • DC
  • New Jersey
  • California
  • Rhode Island

How long can a child stay on a parent’s health insurance plan?

Children can be kept on their parent’s health insurance until the age of 26.

How does my current situation affect my health insurance coverage options?

One of the main reasons health insurance coverage can be so complicated is that everyone’s situation is different, so many plan options are available to meet the needs of people with different situations.

Your options are influenced by a number of factors including your:

  • Job status
  • Income
  • Age
  • Family members in your home
  • Current health status

Do I need specific kinds of health insurance benefits?

Some health plans exist to cover you in the case of an emergency, while others offer a whole world of wellnessThe state of being in good health programs and benefits with the purpose of keeping you healthier longer. See below for two examples.

Pharmacy and prescription drug benefits

 

If you’ve ever needed prescription drugs, you know they can play an important role in keeping you healthy. Maybe you take regular medications — or maybe you’ve only needed medication for specific treatments. No matter what, it’s helpful to know how your benefits work


Vision and dental benefits

Dental and vision benefits are often not included within many health plan options. If they are important to you, consider purchasing a separate, standalone dental or vision plan. 

What is a pre-existing condition? And do pre-existing conditions affect health insurance coverage?

A pre-existing condition is a medical illness or injury that you had before you started to receive coverage from a new health insurance plan. No ACA-qualified insurance plan can reject you, charge you more, or refuse to pay for essential health benefits for any pre-existing condition you had before your coverage started.

Once you’re enrolled, the plan can’t deny you coverage or raise your rates based only on your health.

Health Plan Costs

How much does health Insurance cost?

Some people get their health insurance through their employer, or group insurance. Some decide to purchase it for themselves, or an individual plan (even if family members are included). Others get it through government programs. The cost of health insurance depends on several factors:

 

  •  Age
  • Income
  • Where you live
  • Number of family members needing health insurance coverage
  • Health care use
  • Whether your employer or the government covers part of the cost

What is a deductible?

A deductible is the amount you pay for eligible health care services (e.g., doctor and hospital visits and medical procedures) each year before your health insurance pays its portion of the cost. Individual deductibles can be different for everyone- some may be as low as $0.

What is copayment?

A copayment, or copay, is the fixed amount you pay each time you see a network provider. Some plans require you to pay copays instead of meeting a deductible. Other plans may require you to pay both a copay and meet a deductible.

 

For example, if your plan has a $20 copayment and your doctor's visit is $150 if you:

  • Haven't met your deductible: you'll pay $150 at the time of your visit.
  • Have met your deductible: you'll pay your $20 copayment. The insurance company will pay the rest.

 

The amount you pay for copay or coinsurance is decided by your health insurer and pricing varies. Your copay or coinsurance amount will be listed in your insurance documents or on your ID card.

What costs should I consider when choosing a health insurance option?

When deciding between different health insurance options, the goal is to maximize your dollars for the best quality care, and there are different cost factors to consider with this in mind. Here are a couple of examples.

Premium

The amount you pay, usually monthly, for your plan. Premiums are a fixed amount you pay, whether you use health care services or not.

 

Copayment (or Copay)

A copayment, or copay, is the fixed amount you pay each time you see a network provider. Some plans require you to pay copays instead of meeting a deductible. Other plans may require you to pay both a copay and meet a deductible.


To see other cost examples besides premium and copayment, look through the rest of the FAQ’s.

What is the best way to purchase coverage?

We are here every step of the way to help you through any questions you may have. Get Covered is your resource to help simplify health insurance with clear answers and help you compare your options to find the plan that works for you. No matter who you are, we're here to help you find coverage options you may qualify for!

Ready to see your options? Click here.

Have more questions? Call 800-827-9990 to speak with a licensed insurance agent or click here to get started.