Coinsurance? Premium? Network? It seems like insurance speaks its own language. Don’t worry. We speak that language, too.
And we wrote a dictionary.
For example, if you have a health insurance plan with an actuarial value of 70 percent and you have a $100 doctor’s bill, the insurance company will pay $70 and you will be responsible for paying the remaining $30. Plans with a higher actuarial value will cost more every month in premium, but you will pay a smaller percentage of your actual health care costs.
All health insurance plans are ranked by actuarial value and described as platinum, gold, silver or bronze. Platinum plans have an actuarial value of 90 percent; gold has a value of 80 percent; silver is 70 percent and bronze is 60 percent. Except in unique circumstances it is not possible to buy health insurance that pays less than 60 percent of medical spending.
For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
A co-pay is usually required at the time of service. So, if you have a $15 co-pay for every doctor’s office visit, for example, you’ll need to pay $15 to the doctor the day you visit.
Cost sharing in Medicaid and CHIP also includes premiums.
You may hear the term “cost sharing reductions.” This is a federal subsidy distributed as discounts that help reduce out of pocket cost for healthcare expenses. More about these discounts can be found on our Lowering Your Costs page.
For example, if you have a $2,000 deductible, you will pay for the first $2,000 of health care you receive in a year before your insurance begins to pay for anything. Your deductible may not apply to all services.
For example, your insurance must pay for preventative health care or other services even if you haven’t paid your full deductible, yet.
This level is determined by the U.S. Department of Health and Human Services. FPL varies according to family size and is adjusted annually for inflation.
Eligibility for federal tax credits and Medicaid is based on a family’s percent of the federal poverty level. Households with income between 100 percent and 400 percent of FPL are eligible for some kind of insurance purchasing financial assistance.
2016 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA
|Persons in family/household||100% of FPL||138% of FPL||400% of FPL|
For families/households with more than 8 persons, add $4,160 for each additional person.
You may also have heard the word “exchange” to describe the same thing.
Insurance sold in healthcare.gov in Montana is identical to insurance sold outside the website. Healthcare.gov is the only website that communicates with the federal tax agency, which must verify your eligibility for tax credits.
With most health insurance, if you receive health care services from an out-of-network provider, you will pay a significantly higher out-of-pocket costs.
You can find a list of a company’s provider network on the company’s website. We recommend checking the network before you buy your plan. If you are buying insurance through healthcare.gov, you will find a link from that site to the insurance company site, which will include a list of network providers.
Don’t assume every provider in your community is in every company’s network. Emergency care is always considered in-network, even if the hospital where you were treated is not in your company’s network.
Open enrollment for 2017 begins November 1, 2016 to January 31, 2017.
Individuals may be able to apply for individual health insurance outside of open enrollment if they have a qualifying life event.
Nearly 85 percent of Montanans who bought health insurance through healthcare.gov for 2016 received a tax credit to bring down their costs.
For more information, check out our Lowering Your Costs page.