Full Coverage Plans
Federal regulated plan covering:
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services
- Prescription drugs
- Rehabilitative and habilitative services
- Laboratory services
- Preventative and wellness services and chronic disease management
- Pediatric services, including oral and vision care
November to December 15th is the standard enrollment period, otherwise you may apply under these special conditions:
- Lost Health Insurance Coverage- Your employer, COBRA, a plan you bought, spouse/dependent, medicare, medicaid or CHIP
- Household Change- Had a baby, placed a child into foster care, adopted a child, got legally separated and lost health insurance, your employer, or COBRA
- Moved- New ZIP Code or county, or from out of the country
- Residency- Became U.S. citizen, gained status as a native american, or released from incarceration
- Military Service- Started or ended military service
State regulated plan. Plans vary state to state so you want to make sure you are covered for what you need. Typical exclusions:
- Maternity (Pregnancy)
- Dental & Vision
Hospital & Doctor
Coverage for doctor visits and hospital care
Helps in covering expenses from unexpected injuries
Covers illness and injury expenses which incurred while traveling
Insurance for a specified illnesses:
- Hear Attack
- Organ Transplant
Provides income due to disability that prevents insured from working
In the event you cannot take care of yourself this coverage can provide:
- Assisted living facility
- Nursing Home
Exclusive Provider Organization (EPO)
Expect lower out-of-pocket payments. Your physician choice is limited to the network and will have a designated primary care physician. This physician will have to provide a referral if you want to see a specialist.
Health Maintenance Organization (HMO)
Expect lower out-of-pocket payments. You have a more limited choice of physician, who will become your primary care physician, and you need a referral from your primary care physician to see a specialist to be covered.
Health Savings Account (HSA)
A tax-free savings account that is used within an HSA-compatible high deductible health plan to pay for qualifying medical expenses.
Preferred Provider Organization (PPO)
Expect higher out-of-pocket payments. Your physician choice and specialist choice must be in an approved network, but you don’t have to designate one physician as your primary care physician.
High Deductible Health Plan (HDHP)
Expect higher out-of-pocket expenses. After, the maximum out-of-pocket expense is reached plans usually pay 100% of the expenses.
Expect no insurance coverage on your primary care physician. On the other hand, you will typically have high coverage on referred specialist.
A co-pay may disregard the deductible, co-insurance and out of pocket maximum. The co-pay is subject to specific services on your plan. For example, if your co-pay is $5 per generic brand prescription, each time you go to the pharmacy to obtain this or get a refill you will need to pay $5.
A dollar amount required for the insured to pay before the insurance company will pay your medical bills. This dollar amount may be per person/family on your plan.
Your family deductible is $900 and your individual deductible is $1,000. You went to the doctor for an annual checkup costing $200 and the following week your son went to the ER for an injury with a bill of $1,300, then the insurance company will pay $500 (1,000 – 200 – 1,300) of your son’s bill along with paying co-insurance for each bill afterward.
After a deductible is meet, co-insurance for each medical bill is implemented.
Co-Insurance for doctor visits are 80%, which means you pay 20% of the bill. If the bill was $1,000, then you would pay $200.
Out of Pocket Maximum
The maximum amount an insured would pay after a deductible was meet.
The deductible was $1,000, co-insurance is 80% and the out of pocket maximum is $1,500. You received an injury with a bill of $1,500, you would pay $1,100 (1,000 deductible + 20% co-insurance * 500 remaining bill after deductible was met). Your son was sick and admitted to the hospital a month later leaving a bill of $10,000, you would pay $1,400 ( 10,000 bill * 20% co-insurance – 100 from going over deductible previously). Any more medical bills after this will be covered completely covered.
The insurance company paid $400 ((1,500 bill – 1,000 deductible) * 80% co-insurance) for the first incident and $8,100 (10,000 bill * 80% co-insurance + 100 from the insured going over deductible previously) for the second.
The dollar amount that you pay consistently to the insurance carrier to own an insurance policy.
Inpatient care is when medical conditions require you to stay overnight at a medical facility (eg. Hospital). Outpatient care is when your medical conditions are resolved and you do not need to stay at the medical facility overnight.
Affordable Care Act (ACA)
The legislation that standardized health insurance and made it mandetory insurance
Days of Coverage
Short-term health insurance plans have a specific amount of days that you are covered for. You will be able to specify the amount of days (30-366).
The maximum amount of dollars an insurance company will spend on your insurance plan
- Autism Spectrum Disorders
- Dental Services
- Diagnostic Testing
- Doctor Office Visit
- Durable Medical Equipment
- Emergency Room
- Home Health Care
- Hospital Services
- Medical Supplies
- Mental Nervous
- Newborn Care
- Outpatient Surgery
- Prescription Drugs
- Preventative Care
- Rehabilitation and Extended Care Facility
- Spine and Back Disorders
- Therapeutic Treatments
- Transplant Expense
- Urgent Care
*This is not an all inclusive list and may vary by plan, carrier, and state.