Is this the first time you are presented with the option to purchase your own health insurance?
Let us help you get started by defining some of the most misunderstood health insurance jargon along with 6 categories to pay close attention to when selecting a plan.
1) Network: This outlines the group of hospitals and doctors being offered to you by a particular insurance company; including primary care physicians and specialists.
2) Type of Plans:
a) HMO (Health Maintenance Organization) plans cover medical care provided by doctors and hospitals inside a specific network. HMOs often require members to get a referral from their primary care doctor before going to see a specialist.
b) EPO (Exclusive Provider Organization) plans allow you to access doctors that are only included in your specific network, and generally do not need referrals before going to see a specialist.
c) PPO (Preferred Provider Organization) plans allow you access to doctors and hospitals inside and outside of your selected network and are typically the most expensive plan option.
3) What Tier to Select: Plans are categorized in four tiers.
a) Platinum: Most expensive plan with little or no deductibles.
b) Gold: Less expensive than Platinum plans with relatively low deductibles.
c) Silver: Even less expensive premium with high deductibles.
d) Bronze: These plans have the lowest premium and the highest deductibles.
4) Before benefits are paid, here is what you are responsible for:
a) Your Deductible: The set dollar amount you have to pay before your insurance “kicks” in.
b) Your Co-Pay: The set dollar amount you will have to pay Primary Care Physicians & Specialists at the time of your appointment.
c) Your Co-Insurance: Set percentage for certain services you need.
5) Be aware of your out of pocket maximum.
This is the total dollar amount you will be responsible for in a given period, either a calendar year or contract year. This amount will include your deductibles, co-insurance, & co-pays. Once you have reached this amount in your given period, your medical expenses will be covered 100% until the end of that period. At that time, it will start all over again. Please note, you will always be responsible for your premium payments.
6) Prescription Drugs: they are generally broken down by 3 tiers
a) Tier 1- generic drugs subject to the lowest co-pays
b) Tier 2- brand name drugs subject to higher co-pays
c) Tier 3- non-formulary drugs subject to the highest co-pays with some plans even having a deductible or limit within this
Hopefully, we have provided you with a basic understanding of health insurance so that you are able to make a more informed decision. Open enrollment for 2017 begins November 1st. Feel free to contact us today to help you make the choice that best fits the needs and budget of you and your family.