By now most people know they must have health insurance coverage or pay a penalty. But, did you know:
Health insurance can seem complicated so we’ve put together basic information and common terms we hope you will find helpful.
If you don’t have health insurance through a job, Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), or another source that provides qualifying coverage, the Marketplace can help you get covered. Most people who apply qualify for a premium tax credit that lowers their monthly insurance bill. Some also save on out-of-pocket costs like deductibles and copayments. If you don’t have health insurance, you may have to pay a fee.
Open Enrollment 2016 started November 1st, 2015 and ends January 31, 2016. Open enrollment is the only time you can get Minimum Essential Health Coverage through the Health Exchange (which may include Tax Credits) for 2016 without qualifying for Special Enrollment. Make sure to change plans or verify information by December 15th, 2015 for plans starting on January 1st, 2016.
Your plan and cost assistance may auto-renew or you may be auto-enrolled in a similar plan. You can be automatically re-enrolled on December 15th for coverage to begin January 1, 2016 if you:
The fee for not having health insurance that meets the minimum essential coverage in 2016 effects individuals who file taxes. The fee is calculated 2 different ways: 1) as a percentage of your household income and 2) per person (in 2016 the fee has increased to $695 per adult). You’ll pay whichever is higher.
The amount paid to the health insurance company for the plan, usually monthly.
This is a fixed amount consumers pay. usually at the time of service. This amount can vary depending on the type of services accessed. Co-pays are generally less expensive for Primary Care Doctors and generic prescriptions and higher for Specialists.
This is the consumers share the cost of a covered healthcare service- calculated as a percentage.
Don't Confuse Co-Payment and Coinsurance, they are not the same thing. A co-payment is a specific amount that you pay at the doctor's office before you meet your deductible. Coinsurance is a percentage of a provider's charge that you may be required to pay after you've met the deductible.
When you've met your deductible, you'll have to pay coinsurance (usually 20 percent of the provider's charge) until you reach your out-of-pocket maximum. After that, the insurance company will pay for all covered services to the policy maximum for the remainder of the year
Premiums and Co-pays do not count towards the deductible. A deductible is a fixed amount of money you have to pay before most, if not all, of the policy's benefits can be enjoyed. However, in many health insurance policies, you can use some services, like a visit to the emergency room or a routine doctor's visit, without meeting the deductible first. These services will vary with each type of plan.
A deductible amount is calculated yearly, so you have to meet a new deductible for each year of the policy. Before you meet this amount, you are required to pay for health care. Once you meet this deductible, however, the health insurance benefits kick in, and you're then responsible only for paying monthly premiums and coinsurance if applicable.
Deductible amounts vary by plan and can be separated into individual or family deductibles. In general, a family deductible is double an individual deductible, but it can include several members of a family.
A plan with a high deductible will have a low monthly premium, and vice versa.
Out of Pocket Maximum
An out-of-pocket expense maximum, or cap, is the amount that you have to meet in order for the insurance company to pay 100 percent of your policy's benefits. As mentioned before, the out-of-pocket expenses that can be applied toward this maximum amount include your deductible and coinsurance. Co-payments and your monthly insurance premium do not apply to the out-of-pocket expense maximum.
PPO (Preferred Provider Organization)
A health insurance plan that contracts with hospitals and doctors to create a network of participating providers. In exchange for greater access to providers premiums are higher in cost than in an HMO.
HMO (Health Maintenance Organization)
Usually limits coverage to in-network doctors and hospitals who work for, or contract with the HMO. Generally does not cover out of network care except emergency and urgent care. In exchange for more limited access the cost of health insurance premiums are usually less expensive than PPOs.
If you don’t have health insurance, your current insurance is too expensive, or you have questions our Enrollment Specialists are available to help. Start by calling 575-751-5764 or visiting www.TaosHealth.com. This is a free service available to anyone in our community.