Health insurance helps pay for doctor visits, hospital services and medications. After enrolling in health insurance, you will receive a membership package with information about your coverage. Included will be a Summary of Benefits document that explains the key features of the coverage, such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions.
It is important to read the full policy for all details of the coverage.
When you buy insurance, the monthly bill from your insurance company is called a premium. Insurance companies can no longer charge you a higher premium based on your health status or due to pre-existing medical conditions. Insurance companies offering major medical/comprehensive policies, set a base rate for everyone who buys a health insurance plan and then adjust that rate based on the factors listed below.
- Number of family members covered
- Tobacco use
In addition to the premium, the other out of pocket costs include copays/copayment, deductibles, coinsurance, and out-of-pocket limits. Generally, there is a tradeoff in the premium amount and the costs you pay when you receive care. The higher the monthly premium, the lower the out-of-pocket costs when you receive care.
Insured’s do not need to meet your deductible before you receive preventive services from an in-network provider. In addition, there is no copayment or coinsurance for preventive services received from an in-network provider. Preventive services include screenings and immunizations, as well as other services. For a complete listing of preventive services that are covered without cost to you, check with your insurance company as well as on the Marketplace. Preventive services do not include diagnosis or follow-up visits and services for specific problems.
If you visit your health care provider for preventative care such as an annual physical and discuss a specific health problem, you may be charged a deductible or copay/coinsurance for the part of the visit dealing with the problem, even if the initial purpose of the visit was preventive care.
The Affordable Care Act (ACA) requires that individual comprehensive/major medical plans and small group health care plans cover a set of services, which are known as “essential health benefits” (EHB). These benefit packages must include specific coverages including ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vison care.
- Preventive services – like annual checkups, shots, etc.
- Lab Tests
- Prescription Drugs
- Pediatric services – like dental and vision care for kids
- Care before and after your baby is born
- Emergency room visits
- Mental health and substance abuse treatment
- Treatment in the Hospital – known as Inpatient Care
- Services and devices to help you recover after an illness or injury
- Outpatient Care – the care you get without being admitted to a hospital