Health coverage is extremely important in this day and age. It may be offered to you by your employer, or you may have to shop for it on your own. Either way, there is a lot more too it than just choosing what cereal to buy.
You need to be able to answer certain questions before you can make an informed decision. Are your doctors in network? What is the monthly cost of the plan and what is the most you would pay if something catastrophic were to happen?
This is why having a licensed health agent (THAT YOU CAN TRUST), is so crucial in this process. Here, at First Family Health Advisors, we allow you to breathe a little easier knowing there are still agents out there that treat you like family. Putting your needs and budget first is what we do.
DEFINITIONS TO HELP ALONG THE WAY
Premium: - The amount you pay monthly for health coverage. Policyholders must pay their premiums regardless of whether they visit a doctor or use any other healthcare service.
Deductible - The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself before insurance helps. Many insurance plans have both per individual and per family deductibles.
Copay - A defined dollar amount a patient pays for medical expenses. With many plans, a patient pays 100 percent of costs out-of-pocket until they have met their deductible. After that, a patient pays a copay until they reach their out of pocket max..
Coinsurance - The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible. Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%.
If you've paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest.
If you haven't met your deductible: You pay the full allowed amount, $100.
Out of Pocket Max - The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits. For the 2025 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $9,200 for an individual and $18,400 for a family.
In-Network - providers or health care facilities that are part of a health plan’s network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts.
Out-of-Network - Physicians, hospitals or other healthcare providers who do not participate in an insurer’s provider network. This means that the provider has not signed a contract agreeing to accept the insurer’s negotiated prices. Depending on an individual’s health insurance plan, expenses incurred for services provided by out-of-plan health professionals may not be covered, or may only be partially covered by an individual’s insurance company.
TYPES OF HEALTH PLAN NETWORKS
Health Maintenance Organization (HMO) - A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. You’ll need to pick a primary care physician (PCP), and that person will need to give you a referral for you to see a specialist.
Preferred Provider Organization (PPO) - A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers NATIONWIDE. Policy holders receive substantial discounts from health care providers who are partnered with the the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
Exclusive Provider Organization (EPO) - A hybrid organization that exhibits characteristics of both HMOs and PPOs. Like an HMO, an EPO plan requires that members visit in-network providers only; care from out-of-network providers is not covered except in some cases for an emergency. Like a PPO, an EPO plan does not require you to first obtain a referral to see specialists as long as they are in network.
Types of Health Insurance
Group plans - A health plan offered by an employer or employee organization that provides health coverage to employees and their families.
ACA/Obamacare/Marketplace - Coverage facilitated by the government with no underwriting, so they accept all pre-existing conditions. There is also an opportunity for tax credits, or a discount, to reduce premium costs based on income. Open enrollment to get these plans is November 1 - December 15. Outside of that, you need what is a called a qualifying life event to get a special enrollment period.
Share Programs - Not technically insurance. A group of people who band together to help pay for each other’s medical bills. They typically have lifestyle requirements (religious affiliation, no tobacco use, etc.)
Short-Term Health Insurance - Made for transitional periods such as waiting to start Medicare, between jobs, and waiting for other coverage to begin. Usual last between 3 and 6 months depending on where you live.
Medicare - Government sponsored health insurance for those 65+ years old that is federally regulated.
Medicaid - Government program for those with low income.
A Few Links for More Information