Welcome to Insurance Services

Going to the doctor or hospital can be very expensive. Health insurance helps you pay your medical bills. Just like car or home insurance, you pick a policy & pay a premium every month. As of 2014, we’re all required by law to have health insurance & there’s a penalty if you don’t. Previously, it was tough to get health insurance if your employer didn’t offer it, but not anymore. With the Insurance Marketplace, the government is making it easy for you to find & afford the right option.

Each health insurance plan is different & what works for your neighbor might not be a match for you & your family. But no worries—we’ll guide you through the important things to consider before you choose a plan. You’ll need to consider things like benefits (all the things the plan covers), costs (like deductibles, copays & premiums) & networks (what healthcare providers are covered by your plan).

Benefits are services & products your health insurance covers. There are many different combinations of benefits you may get as part of your health insurance plan. The following are a few examples of benefits a plan might cover:

Outpatient care (any medical treatment that doesn’t require an overnight stay at a hospital or medical facility)

Trips to the emergency room

Inpatient care (any medical treatment that requires admission to a hospital)

Care before & after having a baby

Mental health & substance use disorder services (including behavioral health treatment, counseling & psychotherapy)

Prescription services

Services & devices to aid recovery after an injury or help manage a disability or a chronic condition (including physical & occupational therapy, speech language pathology, psychiatric rehabilitation & more)

Lab tests

Preventative services (including counseling, screenings & vaccines to keep you healthy & help manage chronic diseases)

Pediatric services (including dental & vision care for kids)

There are lots of ways to get health insurance, so you can choose the one you’re most comfortable with. You can work with an insurance agent who can help you understand your options, or you can shop online yourself. Try to keep in mind which benefits are most important & why—this will help you focus & find a healthcare option for you.

Costs include a monthly fee called a premium for health insurance. You’ll also pay a fixed amount each time you use a specific service, like visiting the doctor. That’s called a copay. For example, if the plan has a $10 copay for doctor visits, you’ll pay $10 every time you visit the doctor. Depending on the plan & the service, some services are included/free & others have copays.

Important cost terms explained:

A deductible is the amount you pay before your health insurance starts paying. It’s separate from the monthly premium you pay to have health insurance. After you have paid the full deductible amount, your insurance splits the bill with you. Many times, plans with high deductibles have low premiums, & plans with high premiums have low deductibles. Note: some plans count the copay toward your deductible & others don’t, so read the fine print.

Coinsurance is the percentage of the total bill you are responsible for paying after you have reached your deductible. The remainder of your total bill will be covered by your health insurance. For example, if your coinsurance is 20%, for every dollar you spend on healthcare, you’ll pay 20 cents & your insurance will pay the other 80.

Out-of-pocket maximums refer to the highest amount you’d pay for healthcare services in a year. If you reach that amount, your insurance pays 100% of your healthcare bills. Note: this excludes premiums.

Individuals & families can go through the Health Insurance Marketplace or private insurance companies. Those who qualify for Medicaid or the Children’s Health Insurance Program (CHIP) can get insurance through them.

Health Insurance Marketplace:

You can compare plans based on price, benefits, quality & other important factors before you choose. The four categories of plans are Bronze, Silver, Gold & Platinum. You’ll also find Catastrophic plans for those under 30 years old or who have very low incomes.

Open Enrollment happens from 10/15-12/7 each year, with coverage beginning 1/1 of the next year.

If you are looking for insurance outside of this period, you may establish eligibility in two ways:

1. If you qualify for a special enrollment due to a life event like losing other coverage, getting married or having a baby

2. If you qualify for Medicaid or the CHIP, you can apply any time

What you need to enroll:

1. A social security number (or document numbers for legal immigrants)

2. Employer & income information for every member of your household who needs coverage (for example, pay stubs, W2 forms or wage & tax statements)

3. Policy numbers for any current health insurance plans covering household members

Private Insurance:

Provided through an employer or purchased individually through an agent.

Enrollment period: varies depending on employer (always open if purchasing individually)

Coverage begins: effective date determined at enrollment

Medicaid:

Provides free or low-cost health insurance to lower-income individuals, families, pregnant women & those with disabilities. Eligibility requirements are determined by state, so check with your local Medicaid office for more information. If you didn’t qualify before you might want to try again, as Medicaid eligibility can change every year. You can apply on the Health Insurance Marketplace.

Enrollment period: open year-round

Coverage begins: effective date determined at enrollment

What you need to enroll:

1. If you’re a citizen: proof of identity, U.S. citizenship or date of birth (e.g., a U.S. passport or driver’s license)

2. If you’re not a citizen: proof of identity, immigration status or date of birth (e.g., a green card)

3. Proof of current income (e.g., pay stubs, a signed income tax return, etc.)

Children’s Health Insurance Program (CHIP):

Covers children of families who don’t qualify for Medicaid, but can’t afford to buy health insurance. Every state operates its own CHIP, often with a unique name—some states combine Medicaid & CHIP. You can apply on the Health Insurance Marketplace.

Enrollment period: open year-round

Coverage begins: at enrollment

Yes!

Here's how: the government is helping some people pay via subsidies & tax credits. Based on your family size, income, etc., you might be eligible for a subsidy that could decrease the cost of your premium.

Note: quitting smoking may help decrease your premium too. Find out more about how to quit smoking by talking to a DX Offers Mall pharmacist. See other ways to reduce your rate at the bottom of this page.

To find out what you & your family’s healthcare needs might be it’s helpful to look at your healthcare spending from last year (unless you’re expecting major changes). Just remember that unplanned healthcare costs can pop up anytime, but having health insurance can offer some protection in those instances.

To help you determine what’s important to you, rate the following on a scale from 1 to 3 based on importance (1 is mandatory, 3 not so much).

Premiums vs. deductibles: Would you rather have lower premiums & higher deductibles (pay less in premiums per month, but more out-of-pocket when you need medical care) or have higher premiums & lower deductibles (pay more per month, but less when you need to see the doctor)?

Prescriptions: Take a lot of these? Make sure they’re covered by your plan.

Vision & Dental: Do you need vision care? Would you like to have regular dental exams?

Access to personal/wellness tools & coaching: are you managing a chronic disease? Do you want tips on maintaining a healthy lifestyle?

A provider network is a group of doctors, healthcare providers & pharmacies who have contracted with a health insurance company to offer their products & services at a pre-agreed upon rate. You can use providers & pharmacies outside the network, but this will require you to pay more out of pocket. If you have a specific doctor you want to see, you should make sure they’re in-network for the plan you choose.

There are two main types of plans to get to know before you buy. Also, if you have a specific doctor you’d like, that’s key.

If you choose an HMO (Health Maintenance Organization), you’ll have to see a doctor within your insurance network. You’re also required to have a primary care physician (a personal doctor), & if you need to see a specialist or get X-rays or labs, you’ll need to first go to your personal doctor & then get a referral from him or her.

If you sign with a PPO (Preferred Provider Organization), you’re not required to have a Primary Care Physician & you don’t need a referral to see specialists, or to get labs or X-rays. You can choose to see any doctor—in or out of the network. Keep in mind that choosing someone outside will require you to pay the doctor more & you’ll have to file an insurance claim to get reimbursed.

Ancillary services - Services provided by a hospital or another inpatient program, which could include X-rays, immunizations, lab work & more.

Annual election period- Also known as “open enrollment”, or AEP, this is the time when you can make changes to your Medicare coverage—it runs from 10/15-12/7 each year.

Benefits: The services or products your health insurance covers. There are many different combinations of benefits you can get as part of your health insurance plan.

Coinsurance: A fixed percentage of the total bill you are responsible for paying after you have reached your deductible. The remainder of your total bill will be covered by your health insurance. For example, if your coinsurance is 20%, for every dollar you spend on healthcare, you’ll pay 20 cents & your insurance will pay the other 80.

Copayment: The fixed amount you pay each time you use a specific service, like visiting the doctor. For example, if the plan has a $10 copay for doctor visits, you’ll pay $10 every time you visit the doctor. Depending on the plan & the service, some services are included/free & others have copays.

Deductible: The amount you pay before your health insurance starts paying. It’s separate from the monthly premium you pay to have health insurance. After you reach your deductible, your insurance helps pay part of your bill based on your coinsurance.

Medical equipment (DME): Doctor-recommended medical equipment that’s used in the home, like walkers, wheelchairs or hospital beds.

Federal Poverty Level (FPL): An income level that’s issued annually by the Department of Health & Human Services—the federal poverty level is used to determine eligibility for certain programs & benefits, which differ by state.

Health Insurance Marketplace: An insurance marketplace that offers individuals & small businesses the ability to shop for qualified healthcare. It provides transparent & competitive information on health plans.

Network: A group of doctors, healthcare providers & pharmacists who have contracted with a health insurance company to offer their products & services at a pre-determined rate. You can use providers & pharmacies outside the network, but it may require you to pay more out of your pocket.

Open enrollment: A one-time, three-month period when you can buy any policy sold on the Marketplace in your state—during this time you won’t be denied coverage or charged more for past or present health problems. For Medicare open enrollment, please see “Annual election period” above.

Out-of-pocket costs: Healthcare costs you pay because they’re not covered by insurance.

Policy: An agreement that outlines what costs the health insurance provider & the individual are each responsible for, along with what health insurance costs are covered.

Premium: The amount you or your employer pays for health insurance—it can be paid monthly, quarterly or yearly.

Premium subsidy: To help people purchase health insurance, the government pays a fixed amount of a healthcare premium—subsidies are based on individual or family income levels.

Prescription drug: Drugs & medications that legally require a prescription.

Prescription drug coverage: Health insurance that helps pay for prescription drugs & medications. Generic prescriptions are the FDA-approved equivalent of brand name drugs & typically cost the least. Brand preferred prescriptions don’t have a generic equivalent—they cost more than generic, but less than brand non-preferred. Brand non-preferred are higher-cost medications that have recently come on the market.

Preventative services: Healthcare services that are meant to prevent illnesses & help keep you healthy through regular checkups & screenings (for example: pap tests, pelvic exams, flu shots & screening mammograms).

Primary care doctor/primary physician: Doctors trained to provide basic care—patients see them first for most health problems. They can also make referrals to other health providers.

Qualified Health Plan (QHP): Under the Affordable Healthcare Act, this is an insurance plan that’s certified by an Exchange or a Marketplace, provides essential health benefits, has limits on cost-sharing (like deductibles, copays & out-of-pocket maximums) & meets other requirements. Public Exchanges are facilitated by the government & Private Exchanges are facilitated by insurance companies.

Referral: For some services or to see a specific medical provider, patients sometimes need a referral from a plan-approved professional.

Specialist: Doctors that treat specific parts of the body, health problems or age groups. For example, some doctors only treat heart problems.

Tax credit: An amount of money you can use right away (in the form of advanced payments) to lower your health insurance premium.