FAQ’s – Frequently Asked Questions

Why is having health insurance important?

What would happen if something major to your health happens? Can you then afford to paying for all the doctor’s cost to diagnose and treat you? Having high medical bills is one of the main reasons people to file for bankruptcy. Not having health insurance can result in the healthcare provider to charge you a lot more than when you have set contracted rates that come with having health insurance. The insurance companies made agreements for the service or drug cost.

Although the health insurance policy may not be enough to cover all the expenses, such as deductibles, or cost from out-of-network providers, they can help with lowering your total cost. 

What does “insurance carrier” mean?

An insurance carrier is another name for insurance company. The terms insurer, carrier, and insurance company are generally used interchangeably. When licensed health insurance agents contract with an insurance company, they often time refer to them as a “carrier”.

What is a healthcare provider?

healthcare provider, or provider, is often used to describe the hospitals and doctors who provide the health care services.

What does premium mean?

The premium is the monthly amount someone pays to keep the insurance policy active. They are typically paid upfront. Not paying the premium can result in loss of coverage.

What does “deductible” mean?

The deductible is the amount someone must pay for health care expenses before the insurance company covers the costs as described in the policy. Often times, insurance plans are based on yearly deductible amounts.

What does “coinsurance” mean?

Coinsurance is the amount refers to someone pays as a portion of the total service cost, often times this is a specified percentage.

What does “copays” mean?

Copays are a flat fee someone pays directly to the service provider. It does not count toward any deductible, and is an additional cost to receive the particular health care service. It can be seen as an access fee.

What does “maximum-out-of-pocket” mean?

maximum-out-of-pocket amount us the described amount in the policy that someone must pay before the health insurance will pay for 100% of additional health care cost for the rest of the year.

What is an “Annual/Calendar Year Maximum” amount?

In Health Insurance plans you will find an “Annual” or “Calendar Year” maximum amount. This refers to the maximum amount the insurance company will pay out during the stated period. Annual refers to a 12-month period after the policy became effective, while a calendar year is through December 31 of that year. Plans on the market place (aka ACA plans) do not have a maximum limit when they stop paying after the deductible and any coinsurance is met. Private insurance often times have these maximums.

What is COBRA health insurance?

The Consolidated Omnibus Budget Reconciliation Act (COBRA) is a health insurance program that allows eligible employees and their dependents to continue the same health insurance received from the employer when the employee loses their job or experiences a reduction of work hours. COBRA extends the same health insurance plan for a period of 18 or 36 months.

The cost of COBRA is usually high because of having to pay 100% for the Health Insurance as usually the employers’ portion received during employment stops, or because of the high benefits level the plan offers.

Can “Self-Pay” save you money?

Self-paying is a term used to describe someone who pays for their treatment directly instead of having the charge being billed to the health insurance company. Some health care providers provide discounts for cash payments, which can be cheaper than what the charge to the health insurance company would be billed for. 

Why? A few reasons to consider are that they avoid additional administration costs because there is no additional invoicing and payment processing needed. Additionally, they have received their money and can put it in the bank right away. 

You would then need to submit the receipt of the service to your health insurance carrier to get reimbursed in accordance with your insurance policy. People with high deductible plans or fixed indemnity benefits may find that they are saving money out-of-pocket after the cost is reimbursed. 

How to go about knowing if self-paying cost less and can save your money?

  1. Call the physician you want to visit ahead of time, and ask If they accept ‘self-pay’ for the service.
  2. What the cost of the service will be
  3. If the cost is less than what they would charge the insurance company.

Give it a try, and perhaps you save yourself some money.

What is considered Major Medical and what does it cover?

Major medical insurance is a long-term, comprehensive health insurance plan designed to cover a majority percentage of the medical costs an average American will pay in a given year, and cover all the 10 essential healthcare benefits, mandated in 2014 in the Affordable Care Act (ACA). 

The 10 Essential Health Benefits are:

  1. Prescription Drugs
  2. Pediatric Services
  3. Preventive and Wellness Services and Chronic Disease Management
  4. Emergency Services
  5. Hospitalization
  6. Mental Health and Addiction Services
  7. Pregnancy, Maternity and New Born Care
  8. Ambulatory Patient Services
  9. Laboratory Services
  10. Rehabilitative and Habilitative Services and Devices

The 10 essential health benefits do not guarantee that your health insurance policy will cover all services you receive within these 10 categories. Let’s take an example on prescription drugs. The various insurance carriers have a drug formulary list that they will cover. must have at least one prescription from every categorized medication covered in their formulary. However, your particular drug your doctor prescribed may not be on the list. You then would need to switch your prescription to avoid paying more out of your own pocket. 

The 10 essential health benefits were designed to make sure that health insurance plans sold on the public market place offer these services for individual and small-group health insurance plans. They may not fulfill all your needs, they are a fair base to make certain that insured adults and their dependents are given the opportunity to receive the needed medical care.

These major medical health insurance plans can be purchased on www.healthcare.gov and do not require the help of a health insurance agent. However, if you want to understand how these plans work and what plan works best for you, feel free to reach out to a licensed health insurance agent. 

Private health carriers often time offer plans that do not need all 10 essential health benefits and may be an option for you to look into and decide if such a plan can work in your particular situation. For these plans, you will need to speak to a licensed health insurance agent.