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Health Insurance Info

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Types of Health Insurance Networks

When it comes to health insurance, it's easy to be confused by the dizzying variety of plans and options. Here's a brief guide to the different types of plan networks available to you.


Health Maintenance Organizations (HMO)

A Health Maintenance Organization (HMO) is a type of health care plan that provides managed care. This means the HMO has specific rules that patients and doctors have to follow. When you join an HMO, you are usually required to choose a primary care physician (PCP). Requiring a PCP is a cost-saving feature of HMOs. PCPs coordinate care and help determine if care is medically necessary, which tends to reduce costs. Your primary care provider has overall responsibility for helping you stay healthy. In most HMOs, you must receive a referral from your primary care provider if you want to see a specialist. To control costs, HMOs set limits on the range of treatments available to members. Except in cases of emergency, most HMOs pay for treatment only if it is provided by doctors and hospitals who belong to the HMO's network.


Preferred Provider Organizations (PPO)

PPO stands for Preferred Provider Organization. It is a type of health insurance plan that typically offers members greater flexibility in choosing treatment and provides maximum benefits (lowest out of pocket expenses) if you visit an in-network physician or provider. With a PPO, you can use any doctor or hospital in the network from a list of preferred providers. Unlike HMO plans, if you want to receive treatment elsewhere, the PPO will pay a portion of the cost. With a PPO plan, you can see any doctor or specialist you want without seeing your primary care physician first to get a referral. Because PPOs have fewer restrictions on treatment than HMOs, they usually have higher premiums.

Exclusive Provider Organization (EPO)

An exclusive provider organization (EPO) insurance plan is a type of major medical insurance that provides minimum essential coverage for illness, hospitalization and preventive health care. As managed care programs, EPOs contract with a network of primary care and other providers to deliver health services to their members. EPO insurance plans manage costs by limiting care to doctors, specialists or hospitals within the plan network. If you use an out-of-network provider, you are responsible for the full cost, except in emergency situations. EPO health plans don't require referrals for specialist visits. However, you may be required to get prior authorization with EPO health insurance. This means that the EPO must review and approve the specialty visit first.

Major Medical Insurance

Major Medical Insurance provides coverage for most types of medical treatment. Your options are not limited to certain doctors or hospitals. Some major medical plans have a deductible. That is, you have to pay a certain amount for medical treatment each year out of your own pocket before the plan starts to pay for your care. Major medical plans have fewer restrictions than HMOs and PPOs, so they usually have higher premiums.


Point-of-Service (POS) Plans

Point-of-Service (POS) plans are similar to HMOs and PPOs. Like an HMO, a POS plan requires you to choose a primary care provider, who will have overall responsibility for your care. You must get a referral from your primary care provider to see a specialist. If you see a specialist in the POS network, you pay no deductible and only a small copayment. (A copayment is a small amount you pay each time you obtain treatment.) You also have the option to see a physician outside the network, but if you do, the plan will pay only part of the expense. A POS plan has fewer restrictions than an HMO, but it does not provide as much flexibility as a PPO.

Short Term Plans - The pitfalls

Although short term insurance plans are more affordable,  research indicates they could cost you a lot more than they save you. 

Read what a government study found.....

http://chirblog.org/u-s-house-investigation-offers-new-evidence-dangers-short-term-plans/

For a description of how short term plans work (and don't work) read more....

https://www.kff.org/health-reform/issue-brief/understanding-short-term-limited-duration-health-insurance/

Which Health Plan is Right for You?

Private vs Public Insurance (Off-Market Place vs Market Place)

Not sure which category you fit in when it comes to health insurance plans?

Public insurance (also known as: Marketplace, ACA or Affordable care act plans, Obamacare, Biden care, government-funded plans, etc) is great for those who:

  • Have ongoing medical conditions and/or expensive prescription medications.

  • Public Insurance is the only major medical coverage out there that cannot deny coverage or claims for major pre-existing conditions.

  • For those who have a low income.

  • The premiums for public insurance will go based on your annual HOUSEHOLD income, BEFORE taxes.

Private Insurance is great for those who:

  • Are relatively healthy.

Private insurance is medically underwritten and will give you lower monthly premiums for being in good health! Private plans offer low deductibles and max out pockets as well. If you are healthy, don’t overpay for your health insurance!

  • People who travel.

Private insurance offers a PPO Network, which gives nationwide coverage and allows you to pick your own doctors and facilities.

ACA - Market Place Plans (AKA Obama Care/Biden Care)

The Patient Protection and Affordable Care Act (also known as ObamaCare and the Affordable Care Act or referred to as ACA) became law in 2010.

ACA Standardized Benefits (AKA Essential Minimum Coverage)

All qualifying ACA plans must offer these 10 standardized essential benefits:

  • Ambulatory patient service

  • Emergency services*

  • Hospitalization

  • Maternity and newborn care*

  • Mental health and substance use disorder services including behavioral health treatment*

  • Prescription drugs*

  • Rehabilitative and habilitative services and devices

  • Preventive and wellness and chronic disease management for adults and children, including 100% coverage for some services*

  • Pediatric service, including oral and vision care*

*Lifetime dollar limits on these essential health benefits have been eliminated.



ACA designates that all qualifying plans be one of four metals: Bronze, Silver, Gold and Platinum. Each is based on the average amount of healthcare costs the plan will cover shown as a percentage of what is covered by your insurance company and what is paid for by you. All insurers participating in the federal or a state healthcare exchange must offer , at minimum, Silver and Gold plans. All metal plans have a shared maximum out-of-pocket amount that you can be charged in any calendar year.


Metal Plan - Insurer Pays / You Pay

Bronze   60% / 40%  

Silver   70%/ 30%

Gold   80% / 20%

Platinum   90% / 10%

In addition, if you are under 30 or meet the criteria for a hardship exemption, you can purchase a catastrophic plan that is compliant with ACA requirements.


Premiums

Premiums charged for any of the qualifying metal plans may be based on:

  • Your age

  • Tobacco use

  • Where you live – determined by rating area

  • The number of family members enrolling with you


Guaranteed Issue

Under ACA, no one can be denied coverage or charged significantly higher premiums because of past health history (pre-existing conditions) or gender. There can be no look-back or waiting periods imposed. Policies are effective on issue. All coverage is renewable, if you choose to renew it. Plans can only be canceled for non-payment of premiums or fraud. The guaranteed issue provision applies to all non-grandfathered plans.


ACA Financial Assistance

You may qualify for financial assistance in the form of tax credits to help with monthly premiums and subsidies to help with out-of-pocket costs.

  • Tax credits can be applied to any of the four metal plans to lower your monthly premiums. They are paid directly to your insurance provider by the federal government. Your tax credit is based on your estimated income for the calendar year, in advance of filing your federal return. Note that if your actual income exceeds the eligibility limit, you will have to reimburse the government for the difference. 

What is my subsidy (tax credit) based on?

Modified Adjusted Gross Income (MAGI) is the figure used to determine eligibility for premium tax credits and other savings for Marketplace health insurance plans and for Medicaid and the Children's Health Insurance Program (CHIP). MAGI is adjusted gross income (AGI) plus these, if any: untaxed foreign income, non-taxable Social Security benefits, and tax-exempt interest.

https://www.healthcare.gov/glossary/modified-adjusted-gross-income-magi/


To PAY for ACA health insurance  https://www.healthcare.gov/apply-and-enroll/complete-your-enrollment/ 


Contact ACA -- https://www.healthcare.gov/contact-us/ 


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