Choosing the right health insurance for your needs can be confusing, but it doesn’t have to be. Use this guide to have a healthy understanding of what you need to consider when comparing plans.
By law, all health insurance plans cover the same set of 10 essential health benefits.
These Include:
Ambulatory patient services (doctor and clinic visits)
Emergency services
Hospitalization
Prescription drugs
Maternity and newborn care
Mental health and substance use disorder services including behavioral health treatment
Laboratory services
Rehabilitative and habilitative services and devices
Preventive and wellness services and chronic disease management
Pediatric services, including dental and vision care
Your health insurance must also cover treatment for pre-existing conditions as well as some screenings, immunizations, and other preventive services before you’ve met your deductible.
In general, plans with lower premiums have higher out-of-pocket costs and plans with higher premiums have lower out-of-pocket costs. The key is to balance how much you pay in premiums per month with how much health care you may need over the year. If you take a lot of prescription medicines and need to be seen by a physician frequently, a plan with a higher premium may be better for you.
Getting Help With Your Decision
Not sure which plan is best for you? Ask your broker or a Community Health Alliance trained and certified representative to go over your options with you. We can help compare benefits and costs so you can make an informed choice. It may take more than 15 minutes to compare health insurance plans, but the time is a good investment when you choose the right plan for you and your family.
Tips on How to Save $$ and Get More Benefit from Your Health Insurance
Establish a relationship with a Primary Care Physician. Allow them to coordinate your health care (not required but recommended)
Go to your doctor’s office for care whenever possible. Avoid emergency room unless a true emergency. Use Urgent Care centers during off hours.
Make certain to use doctors and facilities in the network; they have contracted rates with your insurance plan to help keep costs lower. Makes sure your specialist is in network too.
Take advantage of Insurance Company resources. Call Customer Service for help – especially with chronic disease or continued care issues (they can help you save $$).
TERMS TO KNOW
Plan refers to the benefits you are selecting. Each set of benefits has a plan name.
Bronze, Silver and Gold
Plans are divided into types, generally described as Bronze, Silver and Gold. Each type differs in how much the plan will cover. As the name implies, Gold plan benefits are generally richer than silver. However, they may or may not be the best fit for your personal situation. All plans, whether bronze, silver, or gold, must cover certain “essential health benefits, such as ambulatory services, emergency care, maternity care and prescription drugs
A Primary Care Provider (PCP) is your main health care provider in non-emergency situations: your doctor. You need to make sure that your PCP is in your health plan’s network. You can do this by checking the Provider Directory (available online or by calling the Customer Service Center).
A Specialist is a health care provider who focuses on treating certain conditions.
Urgent Care is when you need immediate medical attention and your PCP’s office is closed or you cannot reach your PCP.
Emergency Care is when you need immediate medical attention due to a life-threatening situation.
Network: The facilities, practitioners, doctors and suppliers your health plan has contracted with to provide health care services. You should search the provider network directory to see if the doctors and hospitals you want are members of the plan network. If a directory is not available, you should call the insurance company and ask. If a provider is “out-of-network,” it may cost you more to receive the service or it may not be covered at all.
Formulary: A list of medications that has been adopted by the plan. Using the drugs in the formulary may lower your prescription costs. If you take prescription drugs, you should check the formulary to see if your medicines are on the list.
Premium: the amount you pay each month for coverage. A low premium may not always be the best for you. There are other costs to consider before making your decision.
Copayment: or copay is an amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or prescription drug. A copayment is usually a set amount, rather than a percentage.
Deductible: The amount you owe for health care services covered by your plan before the plan begins to pay. For example, if your deductible is $1,000, the insurance plan will not pay anything until you’ve met that $1,000. Deductibles may not apply to all services.
Coinsurance: This is your share of the cost of a covered health care service. It is calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductible you owe. For example, if your plan’s allowed amount for an office visit is $100 and you have met your deductible, your coinsurance payment of 20% would be $20. The plan pays the rest of the allowed amount.
Out-of-Pocket Costs: The amount that you must pay before your plan starts to pay 100%. It includes deductibles, coinsurance and copayments. Marketplace plans are capped – you will never pay more than $6,600 for an individual plan and $13,200 for a family plan.
Out of Pocket Maximum is the most you will pay for covered medical treatment during your plan year. It is a fixed dollar amount.