Keeping your body healthy can impact so much more than the number of days you need to take off from work. A healthy body can provide higher energy levels, a more positive attitude, and the strength you need to take on life!

When you buy an insurance plan, you join a group of people looking for similar coverage to combine your healthcare purchasing power. By agreeing to pay a monthly fee in exchange for a variety of benefits, everyone shares in the cost of staying healthy.

Our team can help you find an individual or family medical plan that includes all of the benefits you need … and the federal law requires.

Here are some common terms to help you get familiar with the details of any healthcare plan:

Benefits are payments the plan makes to cover all or part of your medical expenses. Benefits vary according to the plan you choose and usually include a portion of the cost of doctors’ visits, prescription medicine, hospital charges, ER visits, and more.

Claims are filed after you have a medical service, by the doctor or facility that provided those services. A claim is a formal request asking for payment based on the terms of the insurance plan. Your insurance company will review the claim to make sure it is valid. If so, the appropriate amount will be paid out to the insured person or to the doctor or facility that filed the claim.

Co-Insurance is the costs of covered medical services shared between you and your insurance company after the deductible has been met. For example, if a plan has 80/20 coinsurance, the plan would pay 80% of a covered medical expense, while you would pay 20% of the same covered medical expense.

Co-Pays are set prices for various services you may need. For example, you may pay a $20 co-pay for a visit to your primary care physician, or a $100 co-pay for a visit to the ER.

Deductibles are the amount you’re responsible to pay for covered medical expenses (the medical services that are covered under your plan) before your insurance steps in to pay the remainder. When you hear someone say “I’ve met their deductible for the year,” it means they have paid their portion of their healthcare costs. After your deductible is met for the year, your insurance co-pay kicks in to cover up to a maximum annual out-of-pocket amount per person.

Maximum Out-of-Pocket is the most money you will be required to pay in a year for your deductible and co-insurance. A specific dollar amount will be set when you open a health insurance plan. After you’ve paid up to that amount, the insurance company should pay the cost of the rest of your covered medical expenses.

Premiums are the payments you make for your insurance based on rates that are affected by many things, including the cost of the various medical services they will cover and how likely their policyholders, or customers, are to need those services.

The most important decision you will need to make is whether to go with an HMO or a PPO plan.

HMO plans allow you to pick one primary care physician to manage all of your health care services. This physician will provide you with referrals to see other health care professional (except in the case of an emergency). Visits to health care professionals outside of your network typically will not covered by your insurance.
Coordinating your health care through a primary care physician means less paperwork and lower health care costs for everyone.

PPO plans give you the flexibility to go to any health care professional you want without a referral — inside or outside of your network. Meaning you do not need a designated primary physician to manage your health care.
Staying inside your network means smaller copays and full coverage. If you choose to go outside your network, you’ll have higher out-of-pocket costs, and not all services will be covered.

Any questions?

Can you walk me through an example of how medical insurance works?
Let’s say you suffer a serious injury to your leg and need surgery, which means also a hospital stay. Afterward, the costs of your covered medical expenses add up to $35,000. Without health insurance, you would be responsible for paying that entire bill … which would be a huge financial hit! With an insurance policy, your financial responsibility would be much lighter. After a $5,000 yearly deductible, and 20% coinsurance, your maximum out of pocket would be closer to $10,000 … which is still quite a sum to pay. It’s always smart to have a plan in place for these unexpected moments.

How are my premiums determined?
A premium can be based on …

Age: Older adults can be charged more than 3X what a younger person is charged.
Geography: Insurers can charge more in areas where medical costs are higher.
Family Size: An individual versus an individual plus a spouse and/or children.
Tobacco Use: Those using tobacco products can’t be charged more than 1.5X what a non-tobacco user is charged.

It is important to note that a person cannot be charged a higher premium based on gender, current illness, or history of health problems.

Can you explain more about how physician referrals work?
Imagine you get a bad rash on your arm, to receive care you wouldn’t go straight to a dermatologist. First you would go to your primary care physician, who would examine you to determine if a dermatologist is necessary. If your primary care physician can’t help you, he or she will give you a referral to a trusted dermatologist in your network that will. One exception to this rule is that women don’t need a referral to see an obstetrician/gynecologist, or OB/GYN, in their network for routine tests, annual well-woman visits, and obstetrical care.

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