Reposted courtesy of Blue Cross & Blue Shield of North Carolina.
Health Insurance Can Be Complicated. Let Us Help You Understand It!
To make sure you understand your health insurance plan, we’re outlining the most common terms that often confuse people.
The Open Enrollment Period for coverage under the Affordable Care Act (ACA) in North Carolina runs from November 1 to January 15. If you want your coverage to start on January 1, be sure to enroll by December 15. If you miss that date, you can still enroll between December 16 and January 15, but your coverage won’t begin until February 1 – leaving you with a potential one-month gap. Outside of that window, you’ll need a qualifying life event in order to enroll or make changes to your coverage.
Premiums, Benefits & Services
When signing up for your health plan, you agree to pay a monthly fee to the insurance company. This monthly fee is called a premium. Your premium stays the same each month until your plan expires. You’ll want to pay your premium on time each month so your plan stays active.
Benefits are services you receive from your health insurance company. You can find a list of your benefits in the coverage documents you received in the mail. You’ll see there are benefits that are covered, and some that are excluded.
The Difference Between “Covered” & “Covered at 100%”
Covered services and treatment can be filed as a claim, but that doesn’t mean the plan will pay 100%. In most cases, you’ll pay a percentage of the cost, depending on your plan’s deductible, copayments, and coinsurance.
Covered at 100%, which includes preventive care, means there is no extra cost to you. This distinction is important because this can often be confused.
If you ever have questions about what’s covered or not, just call the number on the back of your insurance ID card or your Savers Health representative.
Essential Health Benefits
When the ACA was signed into law in 2010, the government started requiring insurance companies to include what was considered to be essential health benefits on healthcare.gov.
Now, all health plans cover these services for their members:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Laboratory services
- Maternity and newborn care
- Mental health and substance use disorder services
- Pediatric services, including oral and vision care
- Pregnancy
- Prescription drugs
- Preventive and wellness services and chronic disease management
- Rehabilitative and habilitative services and devices
If you are an ACA member, be sure to take advantage of these essential health benefits. For example, see your doctor every year for a physical exam. If you don’t have a primary care physician, contact your insurance company or use their online provider search tool. If you cover any dependent children on your plan, their yearly eye and dental exams are covered, too.
Pre-Existing Conditions
If you had a health problem before your health insurance took effect, then you have a pre-existing condition. Common pre-existing conditions include asthma, cancer, high blood pressure, and diabetes. Insurance companies can’t refuse to cover you or charge you a higher rate because of your pre-existing condition if you are enrolling in a qualified plan.
Excluded Services
These are things that aren’t covered by your health plan. You’ll have to pay out-of-pocket for these services. An excluded service may include cosmetic surgery or teeth whitening. There are other services that will be excluded on any health plan so you want to check ahead of your appointments.
Dedeuctibles, Coinsurance & Cpayments
When your health plan starts, you’ll have to pay for the total cost of your care until you reach a certain amount. This amount is called a deductible, and it works just like your auto insurance deductible. Once you reach this amount, the insurance company starts paying a percentage of the cost of your care.
Coinsurance is the percentage we pay for a covered service after the deductible has been met, and then you pay the difference in the amount owed. Some plans require you to pay a set dollar amount for each doctor’s visit or prescription medicine you buy. This is called a copayment. Your policy may require you to first meet your deductible.
Here’s a real-life example:
Let’s say your deductible is $3,000, and your coinsurance is 80/20. Each time you visit your doctor or pick up prescription drugs, you’ll pay the negotiated rate owed to the doctor or pharmacy. When these treatment costs reach $3,000, the insurance company will start paying 80% of these costs, and you’ll be responsible for 20%.
- After you hit your deductible, if your total bill is $1,000, the insurance company pays $800 and you pay $200.
- Once you reach your out-of-pocket maximum – in this case, $6,000 – the insurance company covers these costs at 100% until your health plan expires.
When you renew your health plan each year, the deductible and out-of-pocket maximum amounts reset.
