Health insurance Archives - Everday Resources

Health insurance is a necessary product that provides you with coverage when faced with medical expenses. No matter your age or current health status, you need to have a health insurance plan in case you get sick or injured.

However, it can be difficult to find the best health insurance when you don’t understand it. There are so many complicated terms and coverage options, but you can learn more and make an informed decision with this health insurance guide.

Types of Health Insurance

Health insurance is broken into two main categories: public and private. Public insurance includes Medicaid, Medicare, and CHIP. The majority of people have private health insurance. An employee typically provides it, or you can purchase it through a marketplace.

Private health insurance can then be broken up even further:

On-Exchange: Private policies sold through government exchanges must cover the ten essential benefits and any other features required by your state. The insurer must offer plans at every metal tier. If you purchase one of these policies, you are eligible for tax credits and cost-sharing reductions.
Off-Exchange: You can you buy a plan directly from a health insurance provider, privately-run market, or third-party broker. No matter where you get it, the plans are still required to offer the ten essential benefits. Unfortunately, you cannot get any subsidies, but they can often provide more options at lower prices.
Employer-Provided: When your employer purchases and manages your insurance, it is part of a group plan. Again, it must follow the rules and offer the ten essential benefits, but you can usually get these plans at lower prices because of the group discount. With employer-provided plans, you don’t have the burden of searching the market for your own insurance.

Types of Private Insurance Plans

Aside from where you get your private insurance, you also need to consider the type of policy that best fits your needs.

Health Maintenance Organization (HMO)

HMO insurance plans restrict you to a selected network of providers, and you don’t get any coverage outside of your network. All of your care and referrals must be coordinated by an in-network primary care physician. Some people find them to be too restrictive, but they offer lower premiums based on deals they have with their network of healthcare professionals.

Preferred Provider Organization (PPO)

If you need more flexibility with your insurance, a PPO lets you choose between in-network or out-of-network providers. Costs will be lower for in-network care, though. You also have the option of seeing specialists without a referral. The flexibility comes at a price, so you can expect higher premiums with this plan.

Exclusive Provider Organization (EPO)

For a mix of the PPO and HMO, get an EPO. These plans still allow you to see a specialist without a referral, but you can’t seek care from out-of-network providers. Because of this, EPO premiums tend to fall in between HMOs and PPOs.

Point of Service (POS)

A POS plan is also a mix between PPO and HMO. You have a primary care provider coordinating your care, but you also have access to out-of-network options! With this plan, in-network care is more affordable, but you need a referral for in-network specialists.

Metal Tiers from Which You Can Choose

As we mentioned with the on-exchange insurance, you have plans at every metal tier, but what is a metal tier? They are simply categories based on how much you pay versus how much your insurer pays:

Platinum: 10% consumer & 90% insurance company
Gold: 20% consumer & 80% insurance company
Silver: 30% consumer & 70% insurance company
Bronze: 40% consumer & 60% insurance company

It’s important to note that these numbers don’t show the exact amount of your portion. It is just designed to give you an overall idea of how much you can expect to pay on your medical costs.

Factors that Determine Your Health Insurance Costs

Lastly, you need to know about the other factors that determine your costs so that you can understand your quote. Your out-of-pocket expenses largely depend on your:

Premium
Deductible
Copayment
Coinsurance
Maximum Out-of-Pocket Expenses

Get Your Health Insurance Quote

Now that you know more about the basics, you can start to find the best health insurance for your needs. If you don’t have an employer-provided plan, we recommend that you start by getting a health insurance quote from several different providers. You can then compare the quotes to find the best policy for your healthcare needs and budget.

Health insurance is the product you purchase to cover any essential or emergency medical expenses. Much like other insurances, many complicated terms and requirements make health insurance confusing for first-time buyers.

However, you must do your research, so you can make sure you have the right coverage for when you need it most. You don’t want to risk being uninsured or underinsured. To learn more about the basics of health insurance, keep reading this guide!

What Does Health Insurance Cover?

There are many different plans and coverage options available, but the government requires all public and private health insurance policies to cover the basics. These required services are referred to as the 10 health essential benefits, and they include:

Prescription Drugs
Pediatric Services
Emergency Services
Hospitalization
Preventative Services & Chronic Disease Management
Addiction & Mental Health Services
Pregnancy, Maternity, and Newborn Care
Laboratory Services
Ambulatory Patient Services
Rehabilitative & Habilitative Services

You may find that your state requires insurers to offer more essential coverage. It is very rare that you would find a state that restricts these 10 essential services.

Commonly-Used Health Insurance Terms

When you start to compare health insurance plans beyond the essentials, you’ll notice that there are many different terms thrown around. Some plans may offer a high deductible with a low coinsurance rate. Others may vary based on out-of-pocket limits. In order to find the right plan for your needs and budget, you need to know what all of these terms mean.

Deductible: The amount of money you must pay before your health insurance starts to cover any of your medical expenses. Your deductible amount resets every year, even if you exceed it the previous year.
Copayment: The flat fee you pay for certain services, such as doctor visits and prescription drugs. It’s also referred to as a copay, and you typically pay it regardless of whether you met your deductible or not.
Coinsurance: Unlike your flat-fee copay, coinsurance is a percentage of the medical costs you have to pay after reaching your deductible.
Out-of-Pocket Limit: This amount is the most that you will be required to pay for your medical costs. Your deductible, copays, and coinsurance all make up your out-of-pocket expenses.

How to Determine the Cost of Health Insurance

Since all of the different factors can vary from plan to plan, you need to know how to calculate your health insurance costs. You shouldn’t compare the premiums alone. Instead, you need to calculate the overall expenses by adding up the five major features of your plan.

Premiums

Your premium is your monthly bill that you pay for health insurance coverage. It’s important to understand that this isn’t the amount you’ll pay for your actual health care services. A low premium often means that you have less coverage, so you should expect to pay more out of your own pocket for your health care expenses. This amount also does not contribute to your deductible or maximum out-of-pocket limit.

Deductibles

Your deductible is the amount that you have to pay before your insurance provider steps in to cover your expenses. A lower premium usually means that you’ll have a higher deductible, so you need to find the balance between what you can afford to pay now versus in an emergency.

Coinsurance

Once you meet your deductible, your insurer helps to pay for a percentage of your health care expenses. You are still responsible for the other portion until you reach your maximum out-of-pocket limit. However, there are some plans that cover 100% of your expenses after you reach your deductible.

Copayment

Before and after you meet your deductible, you’ll have to pay this flat rate every time you go to the doctor or receive prescription drugs. The amount of your copay depends on your insurance provider and the plan you select. A common copay is around $15 to $25 for a routine visit to an in-network doctor.

Maximum Out-of-Pocket Limit

If you want to know the maximum amount of money that you’ll ever have to pay for health care, you should look at the maximum out-of-pocket limit. Aside from your premiums, every cost contributes to the limit, so you’ll never have to pay more than that amount for your health care expenses. Keep in mind that a higher monthly premium usually gives you a lower maximum limit.

Learn More About Health Insurance

Since payments and plans can vary so much from one provider to another, you should request a health insurance quote from several different companies. We suggest that you speak with each provider to learn more about their coverage options. You can also read some of our other health insurance guides to find out more about how it works.