Health Insurance 101

Health Insurance can be really confusing! Watch this quick video to learn how to make the best choices about YOUR health insurance (and avoid some big bills!)

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Most plans operate as either HMOs or PPOs. HMOs are health maintenance organizations. Generally speaking your monthly premiums will be lower, but you must use an in network physician. Should you need to go out of network, except for a true medical emergency you will pay for the entirety of the costs. HMOs only work with in network doctors. You can however apply for a gap exception under specific circumstances, but be warned, there will be a lot of paperwork!

PPOs are preferred provider organizations. They offer more flexibility but generally speaking with higher monthly premiums. You will pay less seeing an in network doctor, but you will still have coverage with an out of network doctor. An in network doctor has agreed to accept whatever amount your insurance has agreed to pay for a given doctor. An out of network may charge more and generally speaking, your coinsurance will be higher. You need to check these terms with your specific plan. Additionally with a PPO, you will be able to arrange to see a specialist on your own. An HMO requires that your primary care physician arranges any visit to a specialist.

No matter which route you choose will have several out of pocket costs to be aware of. They can be a little confusing as well. Specifically Premiums, Deductibles, Coinsurance, & Copays. You should also be aware of Out of Pocket Maximums.

Premiums:
This is the amount you pay on a monthly basis to keep your insurance active. If your company has more than 50 full time employees, they are required to offer health insurance and contribute at least towards at least 50% of the monthly premium.

Deductibles
Your deductible is the amount that you have to pay out of pocket before your insurance kicks in. They can work in a variety of different ways.

First, some plans may have copays for some services even before you meet your deductible. Meaning that instead of paying the full amount, you will be responsible for a set copay before you meet your deductible. Other plans may not cover anything until you meet your deductible.

There can also be deductibles for prescriptions. Sometimes your medical and prescription deductible will be combined so that medical expenses and prescription expenses will go towards meeting your deductible.
Additionally, there are several services that will be covered at no cost even before you meet your deductible.

Copays & Coinsurance:
Copays are fixed amounts for a given service or item. For example a visit to a specialist might be $50 and a trip to the ER might be $250. Or a certain type of medicine might be $5 or $10. You can usually find your copays on your insurance card.

Coinsurance can be a little trickier. With coinsurance you are responsible for a given percentage of the costs with your insurance paying for the remaining percentage. Usually for in network services, your carrier will cover 60-80% of the costs.

OOP Max
Plans also have out of pocket maximums. Basically this is the max that you can pay before your insurance takes over entirely. For the 2021 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $8,550 for an individual and $17,100 for a family.

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[lamusiquefanatique]

Your responsiveness on here is very much appreciated 👍

[annacruz]

Question or clarifications about deductible what if as family our deductible is $, 7000. I spent $3, 000 my husband spent $2, 000 and my daughter $2000. So it’s total of $7, 000 does it mean we met our deductible already or one member example me must completer the $7, 000 before it will kick of. Thanks .

[jmason]

Very informative. Do you have an instant chat option for hearing impaired clients? You have licensed brokers for the state of Michigan, correct?