Things you Need to Know About Health Insurance

Things you Need to Know About Health Insurance
Medicare health insurance Medicare Supplement Medicare Part D

Even before COVID-19 took global, it was difficult to deny the magnitude and importance of health care in our lives. Now, as front-line health-care workers work tirelessly to care for those infected with the virus, health care is front and center as something to be concerned about for yourself and your family.

It is not easy to comprehend health insurance. There can appear to be a plethora of factors to consider, as well as a plethora of moving parts. To even begin to understand if a plan will provide adequate coverage for you and your family, you must first understand how it works.

The enormous cost of health insurance underpins all of the considerations for health care coverage.

Let's start by learning everything there is to know about health insurance. Continue reading to learn about all of the health-care considerations.


Understanding the Fundamentals of Health Insurance

To begin with, health insurance is a type of insurance that is purchased. It covers the insured for medical, surgical, or emergency care.

There are several approaches to health insurance coverage. The insured can pay for medical care and then have the health insurance company reimburse them. Alternatively, the insurance company can make direct payments to the health care provider.

The insured may be required to pay a deductible depending on the coverage.

Your health insurance may not cover all of your costs. In general, the higher the cost of the plan, the more it covers and the less you pay out of pocket. In general, lower-cost plans will provide less coverage.


Insurance Terms You Should Know

There are some other insurance terms to be aware of as you make health-care decisions.

Employer-based health insurance is a plan purchased by the employer for their employees. Employers can obtain tax breaks from the federal government if they purchase this insurance.

The Affordable Care Act Marketplace has already been mentioned. This is where those seeking insurance through the ACA can shop for coverage. Qualified health plans are those that have been approved for inclusion in the marketplace. The plan must adhere to established cost-sharing guidelines like deductibles, copayments, and out-of-pocket maximum amounts.

Many people, particularly those under the age of 30, will choose catastrophic health insurance. This is an additional ACA option. It provides coverage for catastrophic care or if a medical incident costs more than $1,000. It does not cover office visits or prescriptions, but it will cover you if you end up in the emergency room due to an unexpected accident.

Medicare and Medicaid are government-sponsored health insurance programs.

Short-term health insurance covers major medical expenses for those who are covered by it. Most states allow you to be covered under a short-term health insurance plan for up to a year. Although some plans now allow for up to three years of coverage. Short-term coverage is typically less expensive and has coverage limitations.

Gap insurance also provides coverage in the short term. The majority of people who seek gap insurance are in between plans and require temporary coverage.


Other terms to keep an eye out for are:

  • The deductible is the amount paid by the insured before insurance coverage kicks in.

  • A tax credit is a sum of money given to individuals or businesses to help with the cost of health care.

  • Co-pay, which is the amount you pay out of pocket after your insurance company has covered their portion.

  • Premiums are the fees paid to the insurance company for coverage.


Prescription coverage is included in many plans. Many people look for health insurance based on whether or not their prescriptions are covered.

Supplemental coverage frequently includes the option of adding vision or dental insurance.


Also Read: Does Medicare Cover Dental Implants?


Private Health Insurance

There is also private health insurance available. Anyone can purchase private insurance through the ACA Marketplace. Many people also receive private insurance benefits through their jobs.

Most private insurance policies include networks that you are allowed to use or not use. Let's take a look at some private health insurance alternatives.

  • POS: The point of service plans, or POS, are a hybrid of all of the above options. As with the HMO plan, you must select a primary care physician (PCP). This PCP is in charge of coordinating your care. You will have access to PPO network providers, though they will most likely be more expensive. There is also the HMO network, which is less expensive. If you choose that route, you must still obtain a referral from your primary care physician

  • HMO (Health Maintenance Organization): A health maintenance organization, or HMO, is likely to be the most restrictive because it requires the insured to see health care providers who are part of a specific network. A primary care physician will be in charge of all of your medical needs. The PCP is in charge of your care and must write referrals for you to see other providers.

  • PPO (Preferred Provider Organization): A preferred provider organization, or PPO, is less restrictive than an HMO plan. You have the option of seeing a doctor who is in your network. This is frequently done for a lower cost. You are not, however, limited to those providers and may choose to see an out-of-network doctor as well. A PPO plan has the advantage of not requiring a referral to see other doctors from your PCP. PPO plans are more expensive than other options because they are less restrictive.

  • EPO: An EPO, or exclusive provider organization, is a hybrid of the HMO and PPO plans. The benefit of having an EPO is that you do not need referrals to see specialists. You must still designate a primary care physician (PCP), but you cannot see out-of-network doctors.


Also Read Tips on How To Choose A Primary Care Doctor


Public Health Insurance

Most people, as a general rule, have two types of insurance. There is government-provided health insurance, such as Medicare and Medicaid.


Also Read: Medicare Enrollment Periods you Need to Know


Anyone over the age of 65 is eligible for Medicare, which provides free or significantly reduced-cost health care. It is divided into four parts:


  • Medicare Part A for inpatient (hospital) care, for which most people pay no premiums

  • Medicare Part B, for outpatient care, like doctor’s office visits (2020, Part B has a monthly premium of $144.60)

  • Medicare Part C, which is also called Medicare Advantage, and allows you to buy into private health insurance

  • Medicare Part D, for prescription drug coverage


Individuals over the age of 65 can apply for coverage by visiting

Medicaid is a health insurance program for low-income families or individuals. Medicaid eligibility rates vary by state, just as the cost of living varies by state.

The Children's Health Insurance Program (CHIP) is designed to provide coverage to children under the age of 18. Often, families have too much income to qualify for Medicaid coverage. However, private insurance is prohibitively expensive.

CHIP assists families in this bubble in obtaining coverage for their children. Individual qualifying standards should be checked with your state.


Is Health Care Required?

The Affordable Care Act, also known as Obamacare, was signed into law in 2010. The ACA's goal was to provide affordable health care coverage to all Americans. It also required Americans to obtain some form of health insurance at first.

They could be covered by their employer, by private insurance they obtain on their own, or by the ACA health insurance marketplace.

If an American did not comply, they were subject to a tax penalty. Remember, the goal was to provide coverage to all Americans.

The law changed on January 1, 2020. While the Affordable Care Act still requires Americans to have health insurance, there is no longer a tax penalty if they do not comply.

Some states still require residents to have some form of health insurance. These are the states:

  • New Jersey

  • Vermont

  • Rhode Island

  • California

  • Massachusetts

Washington D.C. residents also must have some type of coverage.

Many people believed that health-care costs were prohibitively expensive. While health insurance premiums can be costly, there is a risk if you do not obtain coverage. If you can't fit health-care costs into your monthly budget, you risk an unexpected pile of large bills in the event of illness or accident.

Employers with fewer than 50 employees are not required to provide health insurance coverage under the ACA. The Affordable Care Act (ACA) did establish the Small Business Health Options Program (SHOP), which established a marketplace for small businesses (1 to 50 full-time employees) to obtain coverage.

Employers with more than 50 employees are required to provide health care benefits to their employees. Because of their size, they also do not have access to the SHOP marketplace. More information about the ACA is available at


Also Read: Medicare Plan Terms Employers Need to Know


Health Insurance Enrollment

Enrollment periods in health insurance are a thing. This is the time to enroll in or sign up for the plan. It is also a time when you can make changes to your health plan coverage.

When is the 2021 open enrollment period for health insurance? This is a difficult question to answer, especially in light of the current political climate. In general, they are in November and December for coverage beginning the following year. Many plans, however, hold an open enrollment period in March and April for coverage beginning May 1.

Check your state's guidelines for a definitive answer on open enrollment. If you have private insurance through your employer, they can also provide that information.

Open enrollment restrictions may also be lifted if you have a qualifying change in status, such as a job change or divorce.


Understanding Health Insurance and How to Make It Work for You

Even for those who are well-versed in health insurance, the rules, regulations, and terminology can be overwhelming. This is one aspect of life that necessitates research and attention to detail in order to obtain the best possible coverage at the lowest possible cost.




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