When choosing a plan, consider these important factors:
Choosing a health plan is one of the most important financial decisions you will ever make for you and your family. There is no “one size” fits all option since everyone’s situation will be different. Fortunately, the affordable care act (ACA) simplified the process by standardizing health benefits to make comparing each plan easier. So, you can focus on the more important things such as finding out the cost of th e plans and checking to see if your doctor is covered.
Metal Plan Categories:
There are 4 categories of health insurance plans: Bronze, Silver, Gold, and Platinum. These categories will show you how much on average the health plan will pay towards your medical care and your share of costs. It does not reflect the quality of care of the health plan.
- Platinum – Covers on average about 90% of your medical costs. You pay on average 10%
- Gold – Covers on average about 80% of your medical costs. You pay on average 20%
- Silver – Covers on average about 70% of your medical costs. You pay on average 30%
- Bronze – Covers on average about 60% of your medical costs. You pay on average 40%
Your total costs for health care: The total cost is not only what you pay towards healthcare services (copays, deductibles, etc.) you also need to consider what you can afford to pay each month to keep the coverage.
You pay a monthly bill to your insurance company (a “premium”), even if you don’t use medical services that month. You pay out-of-pocket costs, including a deductible, when you get care. It’s important to think about both kinds of costs when shopping for a plan.
A young healthy adult may require less healthcare and will only need to come in for their annual checkups. They may choose to enroll in a lower premium health plan and understand that they may pay a little more for healthcare expenses when needed. (Suggested metal tier plans: Bronze or Silver)
Some individuals may require more frequent doctor follow-ups and routine treatments. They may choose to enroll in a higher premium health plan since it will cover more of their monthly medical expenses (lower copays, deductibles, etc.). (Suggested metal tier plans: Gold or Platinum)
Your Choice of Doctors – HMO PPO POS , and EPO Some plan types allow you to use almost any doctor or health care facility. Others limit your choices or charge you more if you use providers outside their network.
HMO Doctors – You are required to seek care from your assigned primary care physician. If you need to see a specialist, your primary care physician will refer you to one.
PPO Doctors – You can receive care from any doctor of your choice. You receive prenegotiated discounts from doctors who are co ntracted with an insurance carrier’s network.
Point of Service (POS) Doctors – This is a hybrid of an HMO and PPO plan. Like an HMO, members must designate an in network primary care physician and like a PPO, members can also seek services from out of network providers, however, they will pay for most of the costs.
Exclusive PPO (EPO) Doctors – Similar to a PPO network, you have the option of seeking healthcare services from in network and out of network providers. However, your choice of in network providers will be more limited.
Why Do I Need Health Insurance?
The average cost of a 3-day hospital stay is around $30,000 and fixing a broken leg can cost up to $7,500. Having health insurance can limit your exporsure to these costs and protect you from high medcial expenses that can be devastating to your financial security.
- It’s the Law: The Affordable Care Act (CA) requires individuals to maintain health insurance coverage that meets minimum essential benefits requirements.
Affordable Plans: You can qualify for financial help to pay for your medical plan premiums in the form of a government subsidy. The amount will depend on your annual income.
Protect Your Health: All Covered California health plans includes basic preventive visits at no cost to you. This includes well-woman, physicals, and children’s immunizations. - Financial Protection: Research shows that one of the major reasons for personal bankruptcy is due to a catastrophic illness. Health insurance protects you from unexpected, high medical costs.
Simplified Choices: Medical plans offers standardized benefits to make it easier for you to shop for a health plan. Bronze level plans offers basic coverage at a low premium while the platinum level plan offers the richest benefits and the highest premiums.
Key Healthplan Concepts:
When choosing a health plan, where do you start? Below are some key features of a health plan which significantly can have a significant financial impact. With insurance, you are sharing the financial risks involved with your health. The more coverage you need, the higher the premium and the less times you need to see a doctor, the less coverage you will need. Regardless of which metal plan tier you choose, health plans ultimately have one major goal which is to protect you from financial catastrophe as a result of an unforeseen h eal th issue.
Out of Pocket Maximum: This your total exposure for the calendar year. Once you’ve accumulated enough medical expenses to reach your out of pocket maximum, you and your family will be insured at 100%. This means you will pay nothing towards your medical bills.
Deductible: Most plans, especially PPO’s require you to meet your annual deductible before your insurance covers your medical expenses. Thi s is similar to car insurance, your car insurance will not pay out until you’ve paid your annual deductible. In most cases, you will not have to meet an annual deductible for routine doctor’s visits and for preventive care.
Copays: For most routine services you will pay just a copay for your doctor’s visit. Copays are one of the most attractive features of an HMO as your medical costs are more predictable instead of having to calculate a percentage of costs.
Coinsurance: You typically will need to pay a percentage of your medical costs after you meet your deductible. Most PPO health plans require you to pay your deductible and then your coinsurance.
Negotiated Rates: Not only does your health plan help you pay for your healthcare costs, it also pre negotiates lower healthcare fees. Doctors wh o contract with a health insurance provider agrees to discount their fees based on negotiated rates. This makes it more affordable for con sumers to pay for their healthcare costs and it also helps doctors by receiving thousands of referrals from the health plan provider.
Preventive: Under the Affordable Care Act, each health plan is required to offer preventive checkups and age appropriate cancer screenings at no cost to the member.
