Essential Information for Those Seeking Medical Coverage

Some people say that the United States is the country where you should either live with insurance or not live at all. And this is really so. The US is a country with high-quality medicine. The reason for such a success is also because medical coverage became part of the life of almost every citizen.

In this article, you will learn how health coverage works, how to get the right plan and take a closer look at the best companies in the field.

What Can Health Insurance Give You

Even though every US citizen was needed to purchase medical coverage just a little while ago, today the government no longer requires you to do this. However, some states still abide by old laws and impose penalties on those who refuse to protect their health. Buying health coverage is popular and necessary anyway as it will save you money when you have any health issues. That is why everyone needs to be well aware of this area and have a suitable plan that meets all their needs.

So, health insurance allows you to cover your expenses for various health care services. For example, if you decide to take a preventive examination or see a doctor due to sickness or injury, you can always be sure that your company will pay you part of the costs. Furthermore, various drugs are also part of the medical policies.

How Coverage Works

When You Can Buy Coverage

It's not rocket surgery to understand how this works. First of all, we should make it clear to you that you cannot purchase coverage any day you want. There is a certain period during the year called an open enrollment period. It usually takes place at the end of the year so that people who want to protect their health – and wallets – have time to buy it so that coverage takes effect from the beginning of a new year. The period duration varies from year to year and from state to state, but most often, this period lasts one and a half months.

However, some people can still purchase coverage without this time restriction. This is available for those who have faced unpleasant events in their lives. These events include:

• Moving to another state. Let’s say you are about to move to another state, but your provider does not serve residents in that area. Your only way out is to pull the plug on cooperation with your previous company and make a treaty with a new one even if you will do it in the middle of a year.
• Change in the number of household members.You got married or divorced, gave birth to or adopted a child, or maybe a member of your family passed away leaving you without coverage? All these events make you eligible to buy a plan at any time you wish.
• Loss of work. Many company owners pay some amount of premiums for their employees. But getting laid off or being forced to quit voluntarily leaves you no choice but to purchase your own health policy.
• Getting out of prison. Those who got released from prison do not have any medical protection, so the main thing they need to do is buy coverage as soon as possible.
• Moving to the United States. Undoubtedly, those who come to our country should also protect themselves with cover first.

When You Can Get Paid

It is not enough just to have medical care in order to be reimbursed by your provider. There are certain criteria for being indemnified so continue to read to get to know them.

During the year, you can either get paid or not. It depends on how often you go to hospitals or buy prescription medications and how expensive your treatment is. For you to be refunded from your company, you need to meet a certain expense threshold. This expense threshold is called a deductible. We will describe the basic definitions that you definitely need to know in the next part of the article.

So, once your medical expenses reach the limit, your company has to refund you some expenses. But even when you were reimbursed, you still have to pay for further services, but now the amount will be much less, and your company will pay the rest. How much you will have to pay out-of-pocket in the future depends on what copayment and coinsurance figures are specified in your policy.

Regardless of which plan you get, it must cover all the major treatments, namely 10. It doesn't matter if you get coverage from a public or private company, be sure you can always get the help you need.

A Few Words about Affordable Care Act

Many of you have probably already heard about this program which provides new opportunities for people to get health protection. The Affordable Care Act (you may also see other names such as The Patient Protection and Affordable Care Act, the ACA, PPACA, or Obamacare in the articles) has been available since 2010. This law aims to increase the number of people who can afford to purchase coverage.

Moreover, a website called a marketplace was created as part of this law. There, people can buy any coverage they like from both government and private companies. All coverage is divided into certain tiers that allow you to choose how much money you would prefer to spend on services and how much money must be paid by your company. Let's now take a closer look at some of the main changes this program has provided.

• Everyone, regardless of gender and pre-existing conditions, has a right to buy coverage.
• Lifetime coverage limits were lifted.
• Children may be covered by their parent's plans up to the age of 26.

Basic Definitions

Premiums

We would like to start with premiums. When you purchase a plan, you need to regularly make payments since that day. Most often, people pay fees once a month, although sometimes you can choose to pay for the entire year at once. These fees are called premiums. The lower your monthly payments, the higher your deductible. And vice versa.

Deductible

Each policy specifies its own deductible rate. This refers to the limit that you must reach for your company to start paying for your medical expenses. Until you have reached this threshold, every time you seek help from healthcare specialists, you pay for their services on your own.

Copayment

You will often come across the name copay. Copay is a certain amount of your own expenses when you have already reached your deductible. This amount is always equal for all services. It doesn't matter how much the treatment actually costs, you will always pay the same. The rest of the cost goes to your company's account.

Coinsurance

This concept is directly related to the previous one. But if the copay is a certain amount, then coinsurance is the percentage of the service cost that you have to pay. This amount may vary since the cost of each service is always different.

Suppose that your maximum out-of-pocket spending is $3,000. You pay your own money for each visit to the doctor, and once your expenses hit the $3,000 mark, your provider reimburses you according to the policy terms.

After you have gotten paid, you again need to see a specialist whose services cost $300 per visit. Your policy says that after you reach the deductible, you only have to pay $30 for each visit to the doctor. Regardless of how much a specialist service actually costs, you always pay the same amount. At the same time, your policy specifies that you also must pay 30% of coinsurance for each medical service. This means that in addition to the above amount, you must also pay 30% of the service’s actual cost. Your company coughs up the funding of the remaining 70%. Accordingly, all you need to pay here is $120.

What Plans There Are

When you are looking for coverage, organizations will offer you a huge range of plans to fit every taste. Plans are divided into different categories based on their benefits, reimbursement rates, as well as a provider network.

Plan Types Based on Benefits

Plan Types Based on Provider Network

If we consider various plans in terms of whether they allow you to apply out-of-network specialists, they can be divided into four groups. We have compiled a small table that represents the main features of each group. Below, we will go into a little more detail about each of these types.

• HMOs. This is a fairly common type as it offers several benefits for policyholders. These plans differ in that they provide relatively low premiums and deductibles. However, you can sacrifice money otherwise as HMOs only provide a limited healthcare-professionals network. Thus, if you decide to see a doctor who is not in this network, you will have to pay for his services on your own.
• PPOs. It is the most expensive type out of the four we have presented. Even though it is not in great demand among individuals, about half of the coverage provided by employers to their employees falls into this group. And this is really beneficial since PPOs offer several advantages, for example, there are no restrictions on out-of-network doctors. You can refer to those specialists, but keep in mind that the price will be much higher.
• POSs. If you combine the above two plans, you get a POS plan. It is designed so that every time you seek health care, you have a choice: follow an HMO or PPO plan. Accordingly, the main group of people targeted by this type is people who want to have their own primary care provider but, at the same time, like to seek help from specialists outside the network.
• EPOs. Like HMOs, these plans only allow you to see in-network specialists, but the difference is that you do not need to choose a PCP. This plan can save you plenty of spending since both the premiums and deductible are very low.

How to Choose the Right Plan

Now that you know the basic information about the plans, you can choose the one that suits you best. There are only five steps you need to take to choose a plan.

• Step 1. Take a closer look and compare the plans that are offered on the marketplace. Find out what benefits they offer and if they cover all your medical needs. You can also choose a plan from a private sector organization engaged in this field.
• Step 2. Choose the plan type that suits you best. We talked about the main advantages and disadvantages of each group, so it will be easy for you to do this.
• Step 3. Think about if you want to visit doctors and hospitals that are not affiliated with your organization or if the provider’s specialists network is enough for you.
• Step 4. Determine how often you visit doctors, buy medications, and take preventive examinations. If you are a frequent visitor to hospitals, the higher premiums plan might be a good fit. If you are healthy and do not require a lot of treatment, choose the opposite plan.
• Step 5. Review all the terms and conditions and make sure they include everything you need. If the option you have chosen satisfies you in all regards, purchase the plan and feel protected.

Company Overview

Kaiser Permanente

If you are looking for a top-rated company with a great reputation, Kaiser Permanente is an excellent choice. The company does not operate nationwide but only in certain areas. These areas include Maryland, Colorado, and California, as well as the Northwest and the South Atlantic regions. Among the company’s advantages, we can single out that it provides all types of plans from bronze to platinum. It also receives high satisfaction rates from its customers.

Blue Cross Blue Shield

This is another company with excellent rates. Unlike the previous one, it provides its services in all states, so wherever you live, you can always become its member. The company provides three types of plans: EPOs, HMOs, and PPOs, and the number of specialists included in the latter network is how large you are likely to find someone close to your home

UnitedHealthCare

This organization is part of the largest holding engaged in the healthcare system. It is available throughout the country and offers a wide variety of plans for all groups of society. You can use the company's online services that are available at any time of the day and even contact a specialist by phone. The company has a system of various discounts, however, according to the latest data, the company's members are not that satisfied with its services.

Aetna

It is another insurance provider available across the nation. An excellent reputation and fairly reasonable prices make it one of the best in this area. The company offers all kinds of plans, so you can always choose the one that is really right for you, and a large number of in-network members will save you time to get a hospital or clinic. You can also open an HSA and keep your funds tax-free.

Frequently Asked Questions

How can I find out what my policy covers?

If you do not know what services your policy covers, you can find this information in a special document that your company gives you. If for any reason you do not have this document, you can always contact the company via the Internet or call them directly and inquire about this issue.

Should I really buy coverage?

We never know what the future has in store for us. Medical care in the United States is very expensive, so having coverage will save you your costs anyway. After all, your plan covers not only doctor visits but also hospital care, drug purchases, and various examinations that are necessary to prevent diseases from developing.

What is a short-term plan?

As the name suggests, a short-term plan covers medical services for a specific short period. They are usually purchased by people who need coverage before the official purchasing period starts or when they change jobs.