Health insurance has never been the easiest subject to understand. So we got health insurance experts and actuaries to help us help our members understand common plan details -- so you can choose the plan that's best for you and your family.
The Affordable Care Act has also introduced some new terms into the vocabulary. If you have any questions about health insurance terms or how to understand a health plan, we’d be happy to help -- you can comment on this post or email firstname.lastname@example.org.
Out of Pocket Maximum
Essential Health Benefit (EHB)
Medical Home Rider
What you pay each month in order to purchase insurance. This is, roughly, the “cost” of your plan.
The amount you are responsible for paying towards medical expenses before your insurance coverage “kicks in” to pay the rest. This resets every year.
In general, plans with high premiums will have lower deductibles, and vice versa. This means that usually on plans with lower premiums, you will be responsible for more of the costs of healthcare services before the insurnace company begins to kick in their part of the payment.
The percentage of a medical expense that you are responsible for paying. The insurance company pays for the rest, hence “co-insurance.”
A fixed dollar amount that you pay out of pocket for a medical expense; for example, a visit to the doctor might require a copay of $35.
Out of Pocket Maximum
The maximum amount you will be responsible for paying toward medical expenses covered on your plan. If you have an expense for a service that is not covered on your plan, the cost does not accumulate toward your out of pocket maximum. This includes copays, charges toward the deductible, and coinsurance you have paid over the year. Once you’ve spent your out of pocket maximum for the year, your insurance will cover the rest of the expenses at 100% of the allowed amount for covered services.
HMO (Health Maintenance Organization)
A HMO plan is a health insurance plan that draws on a smaller, more defined network of healthcare providers who serve those insured under that particular plan . In an HMO plan, you’ll need a primary care physician (PCP) who will act as your main doctor and determine what kind of care you need, and refer you to specialists who are also in-network. Should you decide to see an out-of-network doctor or another physician without a referral from your PCP, that cost will not be covered by the HMO plan and you’ll need to pay out of pocket. Any charges you pay for services you receive from the out-of-network doctors or other doctors without a referral will not be included in your out of pocket maximum.
PPO (Preferred Provider Organization)
A PPO is a health insurance plan that also relies on a network of healthcare providers. However, it offers more flexibility when it comes to getting out-of-network coverage and will sometimes pay for out of network care, though usually at a lower rate. PPO plans usually have higher premiums and deductibles.
Things like vaccinations; screenings for depression, cancer, alcohol misuse; diet counseling; and a number of other things qualify as preventive care. This is because they’re intended to nip issues in the bud before you get sick! For a list of services that may be considered preventive care, visit: ( https://www.healthcare.gov/preventive-care-benefits/)
EHB (Essential Health Benefit)
Essential health benefits are things that all ACA-compliant insurance plans are required to cover, and include services such as wellness visits and preventive care. Under the regulation, each State is responsible for helping to set the standard for benefits in their region. The 10 EHB categories are:
- Care at a doctor’s office
- Emergency services
- Hospital care
- Pregnant mother and baby care
- Mental health and addiction treatment
- Prescription drugs
- Rehab and skill development services and devices
- Lab services
- Preventive & wellness services and long-lasting disease management
- Dental and vision care for children
Open Enrollment is the one time per year when health insurance plans are openly accepting new enrollments. This is when you can pick a new plan for the upcoming year, including selecting a new plan and adding or removing dependents to your coverage. For 2015, the open enrollment period goes from November 15, 2014 to February 15, 2015. In order to enroll in new coverage outside of this time window, you must have a qualifying event (such as moving to a new state; certain changes in income; or a change in family size such as a marriage, divorce or new baby).
Medical Home Rider
An optional addition to a health plan that allows enrolled members to receive unlimited, enhanced primary care services for $0 copay at a participating Freelancers Medical location. For 2015, the medical home rider is available on select Empire HMO plans only. By selecting a plan with the rider from Empire, members are agreeing to receive all of their primary care services through the Freelancers Medical program.
A list of all brand name and preferred generic alternatives covered by a plan's prescription drug benefit. The decision to cover a brand name or generic drug is made exclusively by the insurance carrier and is usefully developed by a panel of physicians and pharmacists to ensure there are sufficient options in each drug class. This list is usually provided on the insurance carrier's website and is subject to change at any time.
Under the Affordable Care Act, all health plans now include coverage for prescription drugs. However, the amount of coverage may differ from one prescription to the next and you will often see prescription coverage described in terms of “tiers.” If you are on a specific medication, you should check your insurance carrier’s formulary to make sure it will be covered and to see which “tier” it may fall into:
Tier 1 - these are typically generic and other common prescription drugs. Depending on your carrier’s specific policies, Tier 1 may also include some cost-effective brand-name drugs for common conditions.
Tier 2 - these are typically brand-name prescription drugs on your carrier’s formulary
Tier 3 - these are typically less common and more high cost prescription medications that may be needed for certain conditions, including prescriptions that may need to purchased from a specialty pharmacy
The Affordable Care Act created a new type of plan designed specifically for adults under the age of 30 (and those meeting certain “hardship exemption” criteria). Generally, catastrophic plans have significantly lower premiums than other comparable plan designs and have almost all services apply to a single deductible. You can learn more about catastrophic plans here.
For other questions
For overview and detailed plan information, visit www.freelancersunion.org/2015plans.
For constantly updated Frequently Asked Questions, go here.
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