Catastrophic Health Plans
This plan only covers 3 preventative care visits through a primary care physician before a large deductible is met. This is only considered a Qualified Health Plan for individuals that are under 30 years old or that have been determined that they cannot afford health coverage and are extended a “hardship exemption.”
After the deductible is met, the percentage of charges that you will be expected to pay out of pocket is the coinsurance. For example, if a prescription is $20 and your coinsurance is 20% then you can expect to pay $4 as long as the deductible has been met for the year. Most plans that have a low monthly premium will have a larger percentage for the coinsurance.
The copayment is the fixed dollar amount that you will be expected to pay out of pocket after the deductible is met. Again, if a prescription is $20 and your copayment is $5 then you can expect to pay $5 as long as the deductible has been met for the year. Most plans that have a higher monthly premium will have a smaller fixed amount for the coinsurance.
The dollar amount that you will pay out of pocket for covered healthcare services before the insurance begins to pay. There may be separate deductibles for different lines of care (i.e. prescription drugs may be counted separately) and family plans will normally have a family deductible that covers everyone and an individual deductible for each person. Keep in mind, if the monthly premium is low, the deductible will normally be a larger dollar amount.
Drug Formulary/Drug List
The list of prescription drugs that are covered by an insurance plan.
HIPAA is the Health Insurance Portability and Accountability Act. Enacted in 1996 this act governs health data privacy and storage guidelines. The primary goal is to improve continuity of health insurance coverage, simplify administration of health insurance, improve access to long-term coverage and services, combat waste, fraud, and abuse in the delivery of health insurance and healthcare.
Providers (hospitals, physicians, pharmacies) that have contracts with your health insurance are considered in-network and will have a lower coinsurance or copayment. By selecting care that is “in-network” it will normally cost you less out of pocket.
The Marketplace was created as a result of the Affordable Care Act and is a centralized location provided by the federal government to compare and enroll for medical insurance. Also known as the “exchange”, one can also apply for lower premiums or subsidies to help pay for coverage due to income restrictions. It can be accessed by going to HealthCare.gov but you can also enroll by phone or in-person if you prefer to get help comparing option comparing the different options.
Maximum Out-of-Pocket Expense
Excluding premiums, the maximum out-of-pocket amount is the largest sum of money in which you are financially responsible for paying for covered services over a calendar year after deductibles, copayments, and coinsurances are tabulated.
Maximum Plan Dollar Limit
The maximum dollar amount the insurance company will pay in a year or lifetime on certain types of services.
Minimum Essential Coverage (MEC)
An insurance plan that meets the Obamacare, or Affordable Care Act's, minimum requirements for health coverage. In order to avoid the ACA penalty for not having qualified health coverage, you must be enrolled in a plan that meets the MEC standards. See which types of plans do and do not qualify as MEC.
Obamacare, The Affordable Care Act
Obamacare or the Affordable Care Act was signed into law on March 23, 2010. The goal of the ACA was to increase access to quality and affordable healthcare for Americans.
Providers (hospitals, physicians, pharmacies) that do not have a contract with your health insurance are considered out-of-network and will have higher coinsurance or copayment. By selecting care that is “out-of-network” will normally cost you more out of pocket.
This requires a patient to gain approval from the insurance company to be admitted to a hospital before services provided will be covered. A case manager may also assist in obtaining approval.
Your premium is what you should expect to pay recurringly for your insurance (normally every month). Remember that this does not include deductibles, coinsurance or copayments. While it may be tempting to select the insurance with the lowest premium, if the deductible is high it may be costing more over a year’s time.
Primary Care Physician (PCP)
The PCP is responsible for providing basic care for a patient and will coordinate specialty service if they determine that it is a logical extension of a care plan.
If you have paid your deductible and reached the out-of-pocket maximum through co-insurances, the remainder of expenses are paid 100% by insurance through stop-loss coverage.
For households that have an income between 100% and 400% of the federal poverty level, subsidized coverage options are available through tax credits to assists in addressing the cost of maintaining insurance coverage.
A fee for each month that an individual is not enrolled in a qualified health plan. If you do not have minimum essential coverage, this tax penalty will be paid when filing your federal income tax return. The penalty in 2016 is 2.5% of your household income or $695 for each claimed adult ($347.50 for each claim child) - whichever is the highest dollar amount. The fee for 2017 will be similar to the fee for 2016 with an adjustment of the flat fee for inflation - again, you will be required to pay whichever of the two is the highest payment.