Frequently Asked Questions

Individual & Family

FAQ

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Individual and family health insurance is a type of health insurance coverage that is made available to individuals and families, rather than to employer groups or organizations.

When possible, most people would prefer to have their employer provide group health insurance coverage. But, if this is not an option for you, it is still important for you to seek coverage. You may be pleasantly surprised with the variety and affordability of the individual and family health insurance options available.

Individual and family health insurance plans are usually described as either “indemnity” or “managed-care” plans. Put broadly, the major differences concern choice of health care providers, out-of-pocket costs, and how bills are paid.

Typically, indemnity plans offer a broader selection of health care providers than managed-care plans. Indemnity plans pay their share of the costs for covered services only after they receive a bill (which means that you may have to pay up front and then obtain reimbursement from your health insurance company).

There are several different types of managed-care health insurance plans. These include HMO, PPO, and POS plans. Managed-care plans typically use health care provider networks. Health care providers within a network agree to perform services for managed-care plan patients at pre-negotiated rates and will usually submit the claim to the insurance company for you.

In general, you’ll have less paperwork and lower out-of-pocket costs with a managed-care health insurance plan, and you’ll have a broader choice of health care providers with an indemnity plan.

As a member of a PPO (Preferred Provider Organization) plan, you’ll be encouraged to use the insurance company’s network of preferred doctors and hospitals. These health care providers have been contracted to provide services to the plan’s members at a discounted rate. You typically won’t be required to pick a primary care physician but will be able to see doctors and specialists within the network at your own discretion.

You will probably have an annual deductible to pay before the insurance company starts covering your medical bills. You may also have a copayment for certain services or be required to cover a certain percentage of the total charges for your medical bills.

With a PPO plan, services rendered by an out-of-network physician are typically covered at a lower percentage than services rendered by a network physician.

Though there are many variations, HMO (Health Maintenance Organization) plans typically give members lower out-of-pocket health care expenses but also offer less flexibility in the choice of physicians or hospital than other health insurance plans. As a member of an HMO, you’ll be required to choose a primary care physician (PCP). Your PCP will take care of most of your health care needs. Before you can see a specialist, you’ll need to obtain a referral from your PCP.

With an HMO, you’ll likely have coverage for a broader range of preventive health care services than you would through another type of plan. You may not be required to pay a deductible before coverage starts and your copayments could be minimal. With an HMO plan, you typically won’t have to submit any of your own claims to the insurance company. However, keep in mind that you’ll likely have no coverage at all for services rendered by non-network providers or for services rendered without a proper referral from your PCP.

A POS (Point of Service) plan combines some of the features offered by HMO and PPO plans. As with an HMO, members of a POS plan may be required to choose a primary care physician (PCP) from the plan’s network of providers. Services rendered by your PCP may or may not be subject to a deductible. Also, like HMOs, POS plans typically offer coverage for preventive care visits.

Typically, however, you will receive a higher level of coverage for services rendered or referred by your PCP. Services rendered by a non-network provider may be subject to a deductible and will likely be covered at a lower level. If services are rendered outside of the network, you’ll likely have to pay up-front and submit a claim to the insurance company yourself.

Please note this information may vary by insurance company.

A copayment or “copay” is a specific charge that your health insurance plan may require that you pay for a specific medical service or supply.

For example, your health insurance plan may require a $15 copayment for an office visit or brand-name prescription drug, after which the insurance company often pays the remainder of the charges.

A deductible is a specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims for certain services.

Not all health insurance plans require a deductible. As a general rule (though there are many exceptions), HMO plans typically do not require a deductible, while most indemnity and PPO plans do.

Coinsurance is the term used by health insurance companies to refer to the amount that you are required to pay for a medical claim, apart from any copayments or deductible.

For example, if your health insurance plan has a 20% coinsurance requirement (and does not have any additional copayment or deductible requirements), then a $100 medical bill would cost you $20, and the insurance company would pay the remaining $80.

Under the Affordable Care Act (ACA), you normally need to apply for your individual or family health coverage during the Open Enrollment Period (OEP). OEP is a period of time in which you can enroll for health insurance without experiencing a life event that qualifies you for a Special Enrollment Period (see below for more information). For health coverage starting in 2015, the OEP is Nov 15, 2014 through Feb 15, 2015.

The specific date your 2015 coverage starts depends on when you submit your application. In general, if you apply between the 1st and 15th of the month, your start date is the 1st of the next month. If you apply after the 15th of the month, your start date is usually the 1st of the month after the next. Your exact start date depends on your particular insurance company and the plan you choose. To speed up the process, it’s a good idea to e-sign your application.

Do be aware that after 2015 OEP ends (Feb 15, 2015), you can sign up for 2015 health coverage during a Special Enrollment Period (SEP), if you qualify. You qualify for an SEP if you experience certain life events, such as marriage, birth or adoption of a child, or a change in employment.

When getting quotes for your child(ren) only, enter the child’s gender and birth date in the “Applicant” or first row. Additional children should be entered below in the “Child” rows, but not the “Spouse” row.

However, many health insurance companies require one policy per child. So if you have more than one child, try entering just one child to see a larger selection of plans and prices. You may apply for each child separately.

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