People Also Ask
What does deductible mean?
A deductible is the amount of money you have to pay before your health insurer (or auto insurer or homeowners insurer) begins providing you with coverage. For example, if you have a $500 deductible, you will not receive any payments from your health insurer until you’ve spent at least $500. Deductibles normally reset annually, so you’d have to spend $500 per year on qualifying medical expenses in this example. Typically, the higher the deductible, the lower the cost of insurance. Some insurers have no deductibles while others have deductibles equal to several thousand dollars (these are normally called “high-deductible” health plans).
What does co-insurance mean?
Co-insurance refers to the percentage of medical costs that you are required to pay under the terms of your health insurance policy. When your policy has a co-insurance provision, it is normally expressed in terms of a ratio such as 80-20. In this example, the insurer would pay 80 percent of your covered healthcare costs and you would pay the remaining 20 percent of your costs. The insurer begins paying their percentage of costs after you’ve already paid your deductible (if your policy has a deductible) and you will be responsible for yours up to the coinsurance limit, at which point your insurer becomes responsible for paying for 100 percent of the cost of care up to policy limits.
What is a lifetime limit?
A lifetime limit is the maximum amount of insurance coverage you have or the maximum that the health insurance company will pay out. After the passage of the Affordable Care Act, lifetime limits will no longer be applicable and you will not be able to get cut off from medical coverage even if you incur very large expenses.
What is a pre-existing condition?
A pre-existing condition is a medical condition that you have before the time when you become covered by an insurance policy. For example, if you have diabetes but no insurance, when you later decide to buy insurance, your diabetes will be considered a pre-existing condition. Many insurance companies have limits on coverage for pre-existing conditions, although this too is changing as a result of the Affordable Care Act.
What is a premium?
Premium refers to the amount that you will pay for your health insurance coverage. Several factors affect your premium. One of the most important factors is whether you are insured as part of a group policy such as policies offered by employers (these are the lowest cost policies) or whether you have an individual policy that you simply buy for yourself or your family. Other important factors in determining your premiums include your age, your current health status, any risk factors that make you more susceptible to serious illness, your deductible, your co-insurance agreement, and other considerations that affect the likelihood of the insurance company having to pay a large bill for medical expenses for you.
You should not always assume that the insurance policy with the lowest premium is best. At Selected Benefits, we can help you evaluate all of the factors involved in choosing a Texas health insurance policy so you can get a policy that is the best value. Insurance premiums purchased through Selected Benefits are the same as premiums on policies placed directly through insurance companies.
Are there any PPOs in Texas for self-employed?
We have several ways to insure you including the ACA Marketplace plans, sometimes called “Obamacare”, but unfortunately, there are no PPOs on the Health Insurance Marketplace in Texas. In Texas, you’ll find both open and closed network HMOs, EPOs and POS plans, just no PPOs.
There are other options outside of the Marketplace including short term medical plans, “faith based” plans and indemnity plans, but none of these options are compliant with the Federal healthcare law. These will have limitations such as no, or limited coverage, for pre-existing conditions, maternity and preventative care.
When the Marketplace asks for my income, what do they mean?
They are asking for an estimate of your adjusted gross income in the year in which you are seeking coverage.
If I earn more than my income estimate while on a Marketplace plan, do I have to pay the government back?
When you file your tax return for the year in which you were insured, the IRS will compare the income estimate with your actual adjusted gross income. If your actual income is higher than your estimate, you’ll pay back the IRS the difference in what subsidy you did receive vs. what subsidy you should have received. The same goes if you come in lower than your estimate; if you come in lower, the IRS will likely owe you monies back as you should have received a larger subsidy than you actually did. The point is the IRS will even it up to exactly what it should be; as they always do.
Can I see any doctor I want to?
Well you can if you want, but you generally just pay out of pocket if that physician is out of network on your plan. With any plan, you want to stay in the network of the policy that you have. A few individual health insurance plans may have out of network benefits, but most do not and you will just pay whatever the doctor charges; there will not be a copay. You’ll be best off by just choosing your doctors, hospitals and urgent care practitioners from the network directory of your chosen health policy.
Can I change Marketplace plans anytime I want to?
In a nutshell, no, you cannot. If you are outside of Marketplace open enrollment, you will need a Special Enrollment Provision and those include making a permanent move to a new address, having or adopting a baby, recent release from jail or prison, a new marriage, gaining eligible immigration status or a loss of employer group health insurance coverage. Each of these will give you a 60 day window to be able to enroll in a family health insurance plan on the Marketplace.
My child is no longer eligible for Medicaid, now what?
If your child is either declined for or is no longer eligible for Medicaid, he/she has an automatic 60 day Special Enrollment Provision to enter the Health Insurance Marketplace and purchase a health insurance policy for your family.
My doctor says he accepts a certain insurance carrier, so why don’t I see that doctor in the provider directory for my plan?
For example, if you doctor says he accepts BCBS, you need to understand that BCBS has many, many different provider networks in every State. Some are linked only to employer group health plans, some are linked to Federal government employer plans, some are linked to health insurance policies for individuals through the Marketplace. The bottom line is to make sure that the doctor you want to see is in the network of the plan you have. A doctor’s office simply stating that “we take BCBS” is not good enough.
On a Marketplace plan, what’s the difference between a deductible and out of pocket?
You’ll pay 100% of the fees up to your deductible. After that, you have something called co-insurance and that where, for example, the insurance carrier pays 75% and you pay 25%, but not forever. Once you’ve reached your out of pocket limit, the insurance carrier will pay 100% thereafter for all in-network expenses. Remember, on ACA Marketplace plans, the deductible is always included in the out of pocket maximum. Out of pocket is generally the most you would be on the hook for in any calendar year.
I need a surgery. If the hospital I choose is in my network, can I assume that all the doctors that work there are also in my network?
Definitely not. You want to check the provider directory and make sure any doctors, hospitals or even physical therapists are in the network of the plan you have. If your surgeon wants to use a hospital or facility that is out of your plans network, find another surgeon or you’ll be in for a big surprise and not in a good way.
Why are some people I know able to get free health insurance on the Marketplace, but I pay much higher rates?
ACA Marketplace rates are based on several factors including a person’s age, size of the household, the household income estimate, etc. In very general terms, the lower your income, the less you’ll pay. For those with low income, you can even get better plan designs as the government will give you a “cost share reduction” which will artificially reduce your deductible and out of pocket on Silver plans for those with lower income levels.