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If you have health insurance or are in the market for an insurance plan, you may be feeling terminology overload. What is a deductible? What is coinsurance? How does a Co-pay work? What is an insurance Premium? Individual out of pocket maximum? In this video, we’re going to break down these essential health insurance terms, explain how the costs work for both you and your insurance company, and hopefully help you feel more confident about how your plan works.
Table of Contents:
=============================
0:00 – Intro
0:30 – Overview
1:01 – Your Expenses
1:28 – Insuranace Premium
1:43 – What is a Deductible?
3:13 – What is Copay?
3:50 – FREE Services
4:03 – What is Coinsurance?
4:40 – Individual Out of Pocket Maximum (OOP)
5:00 – Family OOP Max
5:08 – Review
There are 3 levels of health care costs. The higher your costs for the year, the higher up you go. Level 1, You’re paying everything. When your healthcare expenses get to a certain point, you enter Level 2, where you and your insurance company share the costs. If the money you’re paying out of your pocket hits your plan’s cap, you enter Level 3, where your insurance will cover everything further. We’ll circle back to this at the end and it’ll all make more sense.
Now, whether your health insurance is provided through your employer plan, by someone else’s employer plan, self-pay, or a government-issued plan like Medicare or Medicaid, they all have set amounts for premiums, deductibles, co-pay, and co-insurance. These are all terms that represent your out of pocket costs.
🔵 Premium. Think of your Premium like a monthly subscription fee. This is how much you pay each month to keep your insurance active. You pay this even if you never go to a doctor.
🔵 Deductible. Your deductible is an amount specified by your plan that you have to pay in a given year before your insurance pays a dime. For example, if your deductible is set at 00, and the bill for your visit to the hospital was 00, you have to pay 100% of that bill. Bummer.
But if your deductible is set at 00 and the hospital bill is 00, insurance would kick in to help cover half of that bill. Notice that I said it will “help cover” half of that bill…”help.” More on that later. Once you have paid that amount toward covered medical expenses, you’re good until your plan renews. (Usually January 1st)
🔵 Co-Pay. Your co-pay is a set cost you pay for a covered health care service, such as visiting an in-network doctor, a specialist, or buying drugs. Let’s say you go to see your doctor, who charges 0 for an office visit, but your insurance has a co-pay of for doctor’s visits. You pay the and your insurance picks up the rest.
🔵 Co-Insurance. Remember when I said that insurance will “help cover” costs that exceed your deductible? That’s where co-insurance comes in. Co-insurance is a shared cost between you and the insurance company. So, depending on your policy, it may say that after your deductible you pay 20% and your insurance company pays 80%. That’s called an 80/20 policy.
🔵 Individual Out of Pocket (OOP) Maximum: The amount of money that you pay through co-pays, co-insurance, and deductibles. This is your plan’s cap on how much you have to personally pay toward your healthcare costs. After that, 100% is covered by your insurance.
🔵 Family out of pocket max: A cap on the medical costs for a family. After that, your insurance covers the rest for the entire family.
Now let’s bring back the 3 levels example from the beginning. You start on level 1, paying basically everything out of pocket…that is until you reach your deductible. That’s when you go to level 2, where you split the cost with your insurance company through Co-Insurance. If your medical expenses get so high that the total of what you paid reaches your yearly out of pocket maximum, you move to level 3 where all further healthcare expenses for the rest of the year are 100% covered by your insurance plan. When your plan resets for the year, you start back at the beginning.
When I consider purchasing an individual health insurance plan for myself or my family, do I have any financial obligations beyond the monthly premium and annual deductible?
Answers: It depends on the plan, but some plans have the following cost-sharing elements that you should be aware of.
Co-Payments: Some plans include a co-payment, which is typically a specific flat fee you pay for each medical service, such as for an office visit. After the co-payment is made, the insurance company typically pays the remainder of the covered medical charges.
Deductibles: Some plans include a deductible, which typically refers to the amount of money you must pay each year before your health insurance plan starts to pay for covered medical expenses.
Coinsurance: Some plans include coinsurance. Coinsurance is a cost sharing requirement that makes you responsible for paying a certain percentage of any costs. The insurance company pays the remaining percentage of the covered medical expenses after your insurance deductible is met.
Out-of-pocket limit: Some plans include an out-of-pocket limit. Typically, the out-of-pocket limit is the maximum amount you will pay out of your own pocket for covered medical expenses in a given year. The out-of-pocket limit typically includes deductibles and coinsurance. But, out-of-pocket limits don’t typically apply to co-payments.
Lifetime maximum: Most plans include a lifetime maximum. Typically the lifetime maximum is the amount your insurance plan will pay for covered medical expenses in the course of your lifetime.
Exclusions & Limitations: Most health insurance carriers disclose exclusions & limitations of their plans. It is always a good idea to know what benefits are limited and which services are excluded on your plan. You will be obligated to pay for 100% of services that are excluded on your policy.
Beginning September 23, 2010, the Patient Protection and Affordable Care Act (health care reform) begins to phase out annual dollar limits. Starting on September 23, 2012, annual limits on health insurance plans must be at least million. By 2014 no new health insurance plan will be permitted to have an annual dollar limit on most covered benefits.
Some health insurance plans purchased before March 23, 2010 have what is called “grandfathered status.” Health Insurance Plans with Grandfathered status are exempt from several changes required by health care reform including this phase out of annual limits on health coverage.
If you purchased your health insurance policy after March 23, 2010 and you’re due for a routine preventive care screening like a mammogram or colonoscopy, you may be able to receive that preventive care screening without making a co-payment. You can talk to your insurer or your licensed eHealthInsurance agent if you need help determining whether or not you qualify for a screening without a co-payment.
There are five important changes that occurred with individual and family health insurance policies on September 23, 2010.
Those changes are:
1. Added protection from rate increases: Insurance companies will need to publically disclose any rate increases and provide justification before raising your monthly premiums.
2. Added protection from having insurance canceled: An insurance company cannot cancel your policy except in cases of intentional misrepresentations or fraud.
3. Coverage for preventive care: Certain recommended preventive services, immunizations, and screenings will be covered with no cost sharing requirement.
4. No lifetime maximums on health coverage: No lifetime limits on the dollar value of those health benefits deemed to be essential by the Department of Health and Human Services.
5. No pre-existing condition exclusions for children: If you have children under the age of 19 with pre-existing medical conditions, their application for health insurance cannot be declined due to a pre-existing medical condition. In some states a child may need to wait for the state’s open-enrollment period before their application will be approved. Video Rating: / 5
Baffled by premiums, deductibles and out-of-pocket maximums? Here is an overview of health insurance that will help clear things up and give you a better sense of how your money is spent.
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