• Health Insurance Basics & Frequently Asked Questions (FAQs)


    We all complain about the rising cost of health care and health insurance, and yet many of us don’t really know what we’re paying for or if we’re paying the right amount. According to a study by George Loewenstein and his colleagues, only 14 percent of a group of people with employer-sponsored health insurance could define basic health insurance terms such as deductiblecopay, and coinsurance. Can you? You might be surprised. Click here to see if your answers match the definitions.

    Besides knowing the industry jargon, we also have to understand the claims process and how to calculate how much we’re actually supposed to pay for a medical service. If Loewenstein’s findings are any indication, when faced with actual cost-sharing scenarios with the insurance company for a healthcare service, many of us think we know how it works when we really don’t.

    The Affordable Care Act (ACA) provided some help in this area by requiring plans to provide a standard Summary of Benefits document and a Universal Glossary of Terms. But many have argued that it will take more than giving patients more education and information. They argue that the traditional health insurance system itself is too complicated. That may be true, but as a consumer in today’s health insurance marketplace you have to understand and make decisions about your health coverage now that could affect your pocketbook and access to the best care.

    The frequently asked questions below are a good place to begin. You can also click here for a list of additional resources.

    What Is Health Insurance?

    Health insurance is a contract between the insured (you) and the provider of the coverage (the insurance company or government programs, such as Medicare or Medicaid). The provider agrees to cover a portion of your healthcare costs (cost-sharing) in exchange for a monthly, quarterly or annual payment called a premium that is paid by you or by a combination of you, your employer, the state or federal government, or some combination of all of these.

    This contract (a policy or plan, as it is usually called in the insurance industry) between you and the provider spells out how much you will have to pay for your health care and the benefits you will receive. An insurance policy is a legally binding document written to protect your rights and those of the insurance provider under as many circumstances as possible.

    Do You Have to Have Health Insurance?

    Here are some typical reasons people cite for not having health insurance. Each is followed by reasons to reconsider:

    “I can’t afford it.”

    If you think the cost of premiums is high, it is not nearly as high as paying for your own medical care. But if you truly can’t afford to pay private insurance premiums, click here to learn about other options for coverage. You may be eligible for subsidies, Medicaid, or other types of government assistance.

    “I never get sick.”

    You are very lucky. But are you married? Do you have kids who may need medical care? What if you or someone in your family has an accident? If you are only covering yourself, you might also want to consider that as you get older your risk of developing diseases, such as heart disease, increases. You may want to take preventive measures now to stay healthy and avoid the added expense of emergency care and hospitalization later. Click here to learn more about the value of preventive care.

    “If I do get sick, I make enough money that I can pay for it myself.”

    Are you sure? According to Henry J. Kaiser Family Foundation, “medical debts contribute to almost half of all bankruptcies in the United States.” Even if you can afford to pay for anything that could happen to you, do you really want to? You might save some of that money by sharing a portion of the cost with your insurance company.

    “The insurance company always finds some way not to pay and I end up paying for it anyway.”

    Insurance policies and their descriptions of what is and is not covered and the specifics of how costs are shared can be very confusing. The ACA now requires that plans provide a Summary of Benefits and Coverage (SBC) (click here to see an example). You can request an SBC for your plan to know what they should pay for and how much you have to cover. If you think the insurance company didn’t pay for something they should have, you have the right to appeal their decision. Click here to learn more about appealing their decisions.

    “What’s the point when I have to pay so much up front before the insurance company pays for anything?”

    Maybe you haven’t found the right insurance plan. Click here to assess your health insurance needs. You might want to take a look at policies available through the health insurance marketplace or talk with an insurance agent to see if you can find a plan with a lower deductible and a premium that is affordable to you or one with fewer out-of-pocket expenses.

    The Affordable Care Act requires that you have insurance that covers the minimum essential benefits  or pay a penaltyClick here to learn how the penalty is applied and any exceptions.

    What Types of Health Insurance Can You Get?

    Most health insurance plans that have the essential health benefits called for by the ACA fall into the category of managed care plans, which are plans with a network of approved healthcare providers and facilities. These types of plans help insurance companies control costs, which in turn helps to lower premiums. Most managed care plans are HMOsPOS or PPOs, the difference among the three being how frequently the participant wants to use a provider or facility that is not in the network:

    • Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs).These plans typically limit coverage to providers and facilities within the network. You can go to a healthcare provider outside the network, but you will probably have to pay the full cost.
    • Preferred Provider Organizations (PPOs) and Point-of-Service plans (POS) would typically share more of the cost with you than HMOs if you choose to see a provider or use a hospital outside the network. You will still probably pay more to see a healthcare provider outside of the network, but you may not have to pay the full cost. Participants in a PPO can see whatever healthcare provider they want without a referral. POS plans, on the other hand, can see in-network providers without a referral but they need a referral to see someone outside the network.

     Other types of plans include the following:

    • Short-term or temporary plans – these plans only provide coverage for a specified period of time, usually less than a year. They may not comply with Affordable Care Act’s requirements for minimum essential benefits, such as providing coverage for preventive care and accepting applicants with pre-existing conditions, and you may still be subject to a tax penalty. However, these plans can be a good option if you are between jobs or waiting for new coverage to begin.
    • High-Deductible Health Plans (HDHPs) – these plans have a high deductible, but lower premiums. These plans are often used in combination with health savings accounts (HSAs) that allow you to save pre-tax income to pay the higher out-of-pocket medical expenses than you would have with a traditional plan
    • Catastrophic health insurance plans have a very high deductible intended to cover the most serious illness or accident. The premiums for these plans are usually lower than the managed care plans described above, but you may pay thousands of dollars in out-of-pocket medical expenses before you meet your deductible. If you want to purchase this type of coverage from the health insurance marketplace you will have to meet certain age (under 30) and income requirements.

    Where Can You Get Health Insurance?

    Health insurance in the United States is provided by private insurers and the government. You can get it in four ways:

    • From your employer. Most Americans with health insurance get it as a benefit of their employment. Employers purchase the insurance for the entire group of employees, which makes it more affordable by spreading the cost over a greater number of people. In employer-sponsored plans such as these, employees may still responsible for paying at least a portion of their premium, meeting their deductibles and paying a portion of the medical expenses out of their own pockets.
    • Directly from an insurance company. You can buy health insurance directly from the insurance company on your own or with the help of an insurance agent or broker.
    • From the health insurance marketplace. You can buy health insurance through a federal or a state insurance marketplace.

    How Can You Get Insurance?

    • You can get a job that offers health insurance as a benefit of employment.
    • If you recently lost your job, you may qualify for COBRA benefits. COBRA allows you to continue insurance coverage that you had through your employer.
    • Wait until the next open enrollment period and purchase insurance through the health insurance marketplace or directly from an insurance company.
    • Purchase insurance through health insurance marketplace if you’ve had a qualifying event.
    • Apply for benefits from Medicare or Medicaid.

    Why Are Plans Cancelled, and What Can You Do If Yours Is Cancelled?

    Plans can be cancelled by the insurer at any time for any reason; however, insurers are required to give you notice so you can find other coverage. Many plans were cancelled after the passage of the ACA because the insurers decided to discontinue rather than change the plans to comply with the ACA.

    Do You Fall into a Coverage Gap?

    The expansion of Medicaid under the ACA was intended to cover people who could not afford coverage from the health insurance marketplace. So, when the Supreme Court ruled that states are not required to implement the ACA’s Medicaid expansion (and many did not), it created a gap. If your annual income is too high to qualify for Medicaid but too low to afford insurance from the health insurance marketplace, you are in the gap. Click here to see if you’re in the gap and to learn your options for coverage.

    Now that you’ve learned some of the basics of health insurance, would you like to go shopping? Click here for information to get you started.

    Note: This website and the information contained, expressed or implied  herein are made available solely for general informational purposes and are not intended to be legal, tax, health, medical or professional advice or the sole source of information about health insurance coverage or specific health plans. While every effort is made to ensure that this information is accurate and current, SCAI makes no guarantees and disclaims any expressed or implied warranty or representation about its accuracy, relevance, timeliness, completeness or appropriateness for a particular purpose.