Individual Coverage

INDIVIDUAL & FAMILY COVERAGE FUNDAMENTALS

    • I’m looking for health insurance, what are my options? Under the Affordable Care Act (ACA) or Obamacare there are four categories of plans – Bronze, Silver, Gold, and Platinum. All plans have mandated benefits such as drug coverage, maternity benefits, mental health benefits, and pediatric dental coverage. All plans cover preventative services at no charge.
    • What happens if I have pre-existing conditions? Under the ACA, ALL PRE-EXISTING CONDITIONS ARE WAIVED as a condition for enrollment in these plans.
    • What is the difference between each plan category? 
        • Bronze plans have a $5000 – $6000/$10,000 -$12,000 family deductible. Co-insurance ranges from 30% to 50% (where you and the insurance company spit the negotiated medical expenses). The maximum financial out of pocket (OOP) in a calendar year is is $6350/$12700 family, including your deductible and co-insurance. These plans have drug coverage after meeting the yearly deductible. Bronze plans have the lowest deductible but the highest medical financial risks.
        • Silver plans have a $2000/$4000 family deductible. Co-insurance ranges from 20% to 50%. The maximum OOP is $6350/$12700 family. Silver plans usually have co-payments for drug coverage and office visits.
        • Gold plans have no deductible, and 20% co-insurance for all in-network medical and drug costs until one reaches a maximum of $6350/$12700 family.
        • Platinum plans have no deductible, and 10% co-insurance for all in-network medical and drug costs until one reaches a maximum of $4,000/$8000 family. Platinum plans have the highest deductible but lowest medical and drug costs.
    • Can I enroll in one of these plans whenever I want? No, unless there is a qualifying event, you may only enroll in these plans during Open Enrollment. The Open Enrollment period for 2014 ended March 31, 2014. Open enrollment for 2015 begins November 15, 2014, and runs through February 15, 2015. The earliest effective date for 2015 is January 1st.
    • I want to keep my doctor, what should I do? The first thing you should consider before selecting any category of plan is whether you doctors and other providers will accept your specific insurance carrier and plan. Many providers will not accept these new individual plans because the insurance carriers have reduced the providers reimbursement rate.
    • If I want to know the maximum I will pay in medical expenses during the year, should I only consider the size of deductible and co-payment in making my decision? No, the real number to consider is the annual maximum out of pocket (OOP) costs offered by the policy. Once you pay this amount, the insurance company pays all the remaining medical expenses incurred during the calendar year. Deductibles and co-payments are nothing more than a down payment on this OOP number.
    • Will I pay less in monthly premium if I have everyone on a single family policy? No, under the ACA each member of the family will have their own specific premium. These premiums will be added together to determine the total monthly premium for the family.
    • I want a plan that covers branded drugs, does that cost more? All plans have mandated coverage for all drugs. Bronze plans will pay for drugs after one meets the yearly deductible. Silver, Gold, and Platinum plans have co-payments for drugs.

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