Answers to some of the most frequently asked questions about health insurance…
Who’s my carrier and what’s my network?
Carrier - your carrier is the insurance company that stands behind your policy. They’re the ones that ultimately will process & make payments on your behalf for claims (and where your premiums ultimately are paid to!)
There are many different carriers out there, but some of the national carriers that we work with are: BlueCross BlueShield, United Healthcare, AmBetter, Aetna, & Cigna
Network - your network are the facilities, providers & suppliers your carrier (or plan) have contracted with to provide health care services. Generally, networks (or plans) are categorized as one of the following:
Health Maintenance Organization (HMO): type of plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally wont cover out-of-network care (except in the case of emergency). An HMO may require you to live or work in its service area to be eligible for coverage but often provide integrated care & focus on prevention and wellness.
Exclusive Provider Organization (EPO): a managed care plan where services are covered only if you use doctors, specialists & hospitals in the plan’s network (except in the case of emergency).
Point of Service (POS): type of plan where you pay less if you use providers that belong to the plan’s network. POS plans require you to get a referral form your primary care doctor (PCP) in order to see a specialist.
Preferred Provider Organization (PPO): type of health plan where you pay less if you use providers in the plan’s network. You can use providers outside of the network without a referral for an additional cost.
What does deductible mean?
Deductible is one of three terms that are all used to describe the same thing - the payment responsibility timeline aka who’s paying the bills.
Deductible - this is the amount that you pay for covered health care services before your insurance plan will start to pay benefits. For claims dollars $0 - deductible, you’re 100% responsible for payment.
Co-Insurance - this is the amount that you pay for covered health care services after your deductible has been met but before your out-of-pocket-maximum (OOPM), calculated on a percentage basis with the insurance company paying the balance. For example, for a 20% co-insurance for a $1,000 covered services claim, you would pay $200 and the insurance company would pay the $800 balance.
Out of Pocked Maximum (OOPM) - this is the most you have to pay for covered services over the course of a plan year (on an aggregate, cumulative basis). Once you’ve spent this amount for in-network care & services, the carrier is obligated to pay 100% of all covered services claims for the rest of the year.
Co-payment - a fixed amount you pay for a covered service, after you’ve paid your deductible. Sometimes a covered service costs a copayment amount that is NOT subject to a deductible.
Why is my insurance so expensive? Who comes up with these prices?
Health insurance pricing is primarily derived from your three demographic data points by the carrier’s actuarial team, who aggregate all cost data and using advanced statistical analyses create the pricing chart for the current insurance year.
The three demographic points used are:
Age - typically, as we age our average costs of care increases, meaning the younger we are the cheaper we are to insure
Gender - men & women have difference average costs of care with men being cheaper comparatively, and then flips around 50 years old with women being the cheaper than men
Zip Code - the average costs of care in our immediate area are the primary driver of monthly premiums
What does open enrollment mean? Can’t I only get insurance during that?
Open Enrollment (OE) depends on the type of insurance market you’re looking in:
Public Marketplace (ACA Marketplace) - OE runs from November 1 to January 15, unless you have a Qualifying Life Event (QLE) which would make you eligible for a Special Enrollment Period (SPE)
An SPE is typically 60 days from the date of the QLE
Private Marketplace - there is no OE period for a private market plan, you can enroll onto these plans at any time.
Employer Plan - each employer has their own OE period, you will need to ask your HR Department for these dates.
