Insurance Basics

How Does Health Insurance Work?

1
You Have A Health Issue
2
Visit your doctor
4
Your Insurance Provider Reimburses Doctor
3
Your Doctor Bills Your Insurance Provider

Key Terms

40%

of uninsured Americans don't understand key health insurance terms.

Deductible

The amount you pay each year to cover eligible medical expenses before your insurance policy starts paying. After you pay your deductible, you only pay a copayment or coinsurance.

Co-Pay

A flat fee for certain medical expenses; your insurance company pays the rest.

Out-Of-Pocket-Max

The max amount you will pay during a year for coverage. It includes deductibles, copayments, and coinsurance. Beyond this amount, the insurance company covers 100% of eligible medical expenses for the remainder of the year.

Co-Insurance

A percentage that you pay to share the cost of covered services with your insurance provider after your deductible has been paid. For example, if the co-insurance is 20%, the insurance company pays 80% of the claim and you pay 20%.

Premium

The amount you pay for your health plan every month to purchase health coverage.

Essential Benefits

All plans include access to : ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services including behavioral health services, prescription drugs, rehabilitative services, laboratory services, preventive and wellness services, chronic disease management, pediatric services including oral and vision care.

Out-Of-Pocket Max

Your Medical Costs Include All Deductibles, Co-insurances, and Co-pays That Do Not Go Over Your Limits

Your Insurance Company Will Be Responsible for All Medical Costs after Your Limits Are Met

How Much Will I Pay?

Plans are categorized into 5 levels. Your level determines how your medical bill is divided between you and your insurer.

Platinum: Insurance pays 90%. Gold: Insurance pays 80%. Silver: Insurance pays 70%. Bronze: Insurance pays 60%. Catastrophic: Insurance pays less than 60%.

Subsidy Eligibility

27 million+ uninsured Americans are eligible for financial assistance.
53% of uninsured Americans don't know that financial help is available

Eligibility Takes into Consideration:
Household size
Adjusted Annual Income Range
If your household falls into these income ranges, you might be eligible for subsidies:
Household Size
Adjusted Annual Income Range (Approx)

Other Qualifications for Subsidy:

Legal
U.S. Resident
Not
Incarcerated
No Affordable Minimum
Essential Coverage

Basic Plan Types

HMO
Most restrictive. Requires you to choose a Primary Care Physician (PCP) from their provider networks. If you go out of network, you have to pay all medical costs
PPO
Most flexible. You need not stay in-network for health care and do not have to use a PCP. You can go out of network for care, but you will receive less coverage.
POS
POS plans are hybrids of HMO and PPO plans. You must choose a PCP, can go out of network and still receive insurance coverage. Out-of-pocket expenses are substantially higher if you do not get referrals for non-network care.
EPO
EPO plans are hybrids of HMO and PPO plans. You must choose a PCP, can go out of network and still receive insurance coverage. Out-of-pocket expenses are substantially higher if you do not get referrals for non-network care.

Act Now

Having health insurance protects you
from health and financial risks:
Illness

Health insurance covers essential health benefits critical to maintaining your health and treating illness.

High Costs

You pay less for covered in-network health care, even before you meet your deductible.

Bills

Health insurance protects you from high medical costs. 62% of personal bankruptcies in America are caused by medical bills

Penalties

If you have qualifying coverage, you don't have to pay any tax penalties.

Check-Ups

You get free preventive care, like vaccines, screenings, and some check-ups, even before you meet your deductible

We know that comparing health insurance plans and finding the coverage that's right for you can be a complicated and difficult process.

But it doesn't have to

We'll provide you with the tools and information you need to make shopping for health insurance less stressful, allowing you to confidently select the best possible plan for the best possible price, whatever your needs.

With Healthplans.com doing the heavy lifting, you're empowered to make smart decisions regarding the year's most important purchase.

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