Fall is Open Enrollment season. Even if you want to continue with the same health insurance plan you had last year, you’ll need to renew. Now’s the time most people are checking rates, comparing health insurance companies and finding the best deals. We have some frequently asked questions that will help you as you comparison shop health insurance rates online. Whether you’re looking for a low-cost health insurance quote or if you’re applying for Medicare Advantage or Medicare Supplements we’re here to help.
1. How does health insurance work?
Everyone needs health insurance, even when they are young and healthy. One small injury that requires surgery can cost tens of thousands of dollars if you’re not insured. No one anticipates a sudden illness either, and getting sick can be financially catastrophic without health insurance.
A health insurance policy is a legal contract between a policy owner and the health insurance company. It states the terms of the contract, which includes payment by the policy owner, on a regularly scheduled basis, for the contract to remain valid and active. A health insurance policy lists all the responsibilities the insurance company holds in paying for medical care of the policyholder and, possibly, his/her family members if a family plan is in place.
During the underwriting process of an insurance policy, you are evaluated for specific risk categories that are based on age, gender, medical history and other such factors. The amount you pay is called a premium and it is usually paid monthly and is based on your risk factors, which project medical costs for the year.
A deductible is the amount you need to pay before your health insurance begins to pay for any medical claims. In cases where you have a PPO, you pay out of pocket until you hit the limit. For instance, if your deductible is $2500, you will pay for $2500 worth of medical costs and anything over that amount will be covered by your health insurance.
In addition to a deductible, there is usually a co-payment (copay). This is a small portion of the cost you’re responsible to pay for each medical treatment. Co-insurance is the portion the policyholder is responsible to pay as well, but it’s a higher amount than a copay. For example, let’s say Ann had to have surgery that cost $3000. Let’s say her copay is $50, and her co-insurance is 20% (a typical amount). Her share of the cost for the surgery would be 20% of $2950. The insurance would pay the remaining 80%.
There are exclusions to health insurance policies, meaning that there are things you will not be covered for, including elective cosmetic surgery. Some medical providers will also not be covered by your insurance policy. Some policies only accept providers in their own network of physicians.
There are coverage limits on an insurance policy too. Usually, the limits are high enough that the majority of people on a plan do not come close (think half a million to $1 million). Once you reach the limit, the insurer will stop paying for treatment. You will be left with out-of-pocket expenses.
To increase limits, additional underwriting and higher premiums would be necessary to keep the policy active. There is also a maximum for your out-of-pocket expenses, for example $3,000 annually. When you reach that limit, your insurer will pay 100% of your expenses.