The Affordable Care Act (ACA), also known as Obamacare, is a health reform law enacted in 2010 with the goal of making affordable health insurance available to more people. In order to qualify for subsidies, you must meet the following criteria:
There are many different factors that define which health insurance coverage option is best. These factors include:
For example, an individual who has lost their health insurance coverage due to the loss of a job may qualify for Consolidated Omnibus Budget Reconciliation Act (COBRA).
An individual over the age of 65 or under the age of 65 with certain disabilities may qualify for Medicare.
Click here to find out what health coverage options could be available to you..
Health insurance is important even if you are healthy. No one plans to get sick or hurt. Health Insurance can help you financially should you have an accident or illness. Having health insurance also could help you stay healthy with preventive care and early intervention.
Medicare is a government program that provides free or very discounted health care to eligible people who enroll. You may be eligible for Medicare if you:
There are different parts of Medicare to help cover specific services:
Most people do not pay a monthly premium for Part A coverage. Everyone will pay a monthly premium for Part B coverage.
You can either opt in to Part D coverage (called an original Medicare plan), or choose an all-in-one alternative that bundles Part A, Part B, Part D coverage (also called Medicare Advantage Plan).
Click here to see if Medicare may be right for you.
Medicaid is a government program that provides healthcare coverage to eligible low-income:
States operate their Medicaid programs within broad federal guidelines, so eligibility may vary. To learn more, visit www.medicaid.gov.
Dual eligibility is when an individual qualifies for both Medicare and Medicaid. If an individual meets the federal requirements for Medicare and the state requirements for Medicaid, then they are dual eligible.
For example, if you are over the age of 65 and your income is below the federal poverty line, then you may qualify as dual eligible. Click here to check your eligibility.
These metal tiers were set up through the Affordable Care Act in support of individual packages. Each tier covers a certain percentage of health care costs.
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This is usually best for people who are healthy but want coverage for emergency medical situations and do not require frequent visits to a doctor. Wellness visits are covered.
This is often a good plan for an individual or family in need of routine care.
This may be a great plan for someone who needs routine care on a regular basis and prefers to pay a little more each month as opposed to paying more for each visit.
This may be a great plan for someone who regularly needs care and can pay higher monthly premiums while having most if not all costs covered.
A PPO plan is a plan that provides access to a preferred provider organization. With these private plans, individuals may pay less if they use doctors, hospitals, and providers that belong to the network.
Individuals can use doctors, hospitals, and providers outside of the network, but they may pay more out of pocket.
A POS plan is a point-of-service plan. With these private plans, individuals may pay less if they use doctors, hospitals, and providers that belong to the network.
Individuals must get a referral from their primary doctor if they need to see a specialist.
An EPO plan is a plan that provides access to an exclusive provider organization. With this managed care plan, individual care is covered if an individual goes to the doctors, specialists, or hospitals in the network (except in an emergency).
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A high-deductible health plan is a private plan with a higher deductible. The monthly premium for these plans is often lower, but an individual pays more for healthcare costs themselves before the insurance company starts to pay.
There is no longer a federal penalty for not having health insurance. This penalty was eliminated at the end of 2018.
However, some states have their own individual mandates and penalties:
Children can be kept on their parent’s health insurance until the age of 26.
One of the main reasons health insurance coverage can be complicated is that everyone’s situation is different, so many plan options are available to meet the needs of people with different situations.
Your options are influenced by a number of factors including your:
SIMPLIFYING HEALTH PLAN TERMS
Some health plans exist to cover you in the case of an emergency, while others offer a whole world of wellness programs and benefits with the purpose of keeping you healthier longer. See below for two examples.
Pharmacy and prescription drug benefits
If you’ve ever needed prescription drugs, you know they can play an important role in keeping you healthy. Maybe you take regular medications — or maybe you’ve only needed medication for specific treatments. No matter what, it’s helpful to know how your benefits work.
Vision and dental benefits
Dental and vision benefits are often not included within many health plan options. If they are important to you, consider purchasing a separate, standalone dental or vision plan.
A pre-existing condition is a medical illness or injury that you had before you started to receive coverage from a new health insurance plan. No ACA-qualified insurance plan can reject you, charge you more, or refuse to pay for essential health benefits for any pre-existing condition you had before your coverage started.
Once you’re enrolled, the plan can’t deny you coverage or raise your rates based only on your health.
Some people get their health insurance through their employer, or group insurance. Some decide to purchase it for themselves, or an individual plan (even if family members are included). Others get it through government programs. The cost of health insurance depends on several factors:
A deductible is the amount you pay for eligible health care services (e.g., doctor and hospital visits and medical procedures) each year before your health insurance pays its portion of the cost. Individual deductibles can be different for everyone- some may be as low as $0.
A copayment, or copay, is the fixed amount you pay each time you see a network provider. Some plans require you to pay copays instead of meeting a deductible. Other plans may require you to pay both a copay and meet a deductible.
For example, if your plan has a $20 copayment and your doctor's visit is $150, if you:
The amount you pay for copay or coinsurance is decided by your health insurer and pricing varies. Your copay or coinsurance amount will be listed in your insurance documents or on your ID card.
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Out-of-pocket maximum is the most you have to pay for covered health services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan will pay 100% of the cost of covered benefits.
The out-of-pocket limit doesn't include:
Coinsurance is a way for health insurers to split costs with you. It is based on a percentage of covered health care services after you have met your deductible. For example, if you have 30% coinsurance and your doctor’s visit is $150:
The amount you pay for copay or coinsurance is decided by your health insurer and pricing varies. Your copay or coinsurance amount will be listed in your insurance documents or on your ID card.
A premium is how much you pay a health insurance company each month to use a health insurance plan.
When deciding between different health insurance options, the goal is to maximize your dollars for the best quality care, and there are different cost factors to consider with this in mind. Here are a couple of examples.
Premium
The amount you pay, usually monthly, for your plan. Premiums are a fixed amount you pay, whether you use health care services or not.
Copayment (or Copay)
A copayment, or copay, is the fixed amount you pay each time you see a network provider. Some plans require you to pay copays instead of meeting a deductible. Other plans may require you to pay both a copay and meet a deductible.
To see other cost examples besides premium and copayment, look through the rest of the FAQ’s.
We are here every step of the way to help you through any questions you may have. HealthMarkets is your resource to help simplify health insurance with clear answers and help you compare your options to find the plan that works for you. No matter who you are, we're here to help you find coverage options you may qualify for!
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