Mostly Everything I know about Health Insurance

Medicare/Medicaid

Medicare and Medicaid are completely state dependent. The qualifications and limitations vary wildly, therefore you will need to visit your state specific website regarding your eligibility.

Medicare is only for people who are 64 and 1/2 years old or who qualify for disability programs

Medicaid is for people who's income falls below ~$15,000 annually. 

To enroll in either of these plans just look up medicaid or medicare [Your state] and look for the .gov website

Pros: Free, accepted in most places, guaranteed for the qualified

Cons: Getting approved can take weeks, Finding specialists can be difficult, often moved to the back of the line

When to choose private Insurance

• Your employer offers coverage, but the cost for yourself or to add family is too high

• You are self employed or a contractor and your income fluctuates

• You make too much money to qualify for decent marketplace subsidies

• You have a gap in coverage between jobs and your cobra is expensive

• You don't have preexisting medical conditions and only need basic coverage

• You are a business owner with less than 50 employees trying to insure them

Glossary

HMO (Health Maintenance Organization) – A plan requiring members to use a defined network of doctors and usually obtain referrals from a primary care physician to see specialists.

PPO (Preferred Provider Organization) – A plan allowing members to see any provider, but offering lower costs when using providers within the network and typically not requiring referrals.

EPO (Exclusive Provider Organization) – A plan that only covers care within its network (except emergencies) but usually does not require specialist referrals.

POS (Point of Service Plan) – A hybrid plan where members choose a primary care doctor and need referrals for specialists but can still receive limited out-of-network coverage.

HDHP (High Deductible Health Plan) – A plan with a higher deductible and lower premiums that can be paired with a Health Savings Account.

Premium – The monthly amount paid to keep an insurance policy active.

Deductible – The amount a member must pay for covered healthcare services before the insurance company begins paying.

Copay (Copayment) – A fixed dollar amount paid for a specific service, such as $30 for a doctor visit.

Coinsurance – A percentage of the cost of a service that the member pays after the deductible is met (for example, 20%).

Out-of-Pocket Maximum (OOP Max) – The maximum amount a member must pay in a year for covered services before the insurance plan pays 100%.

Network – The group of doctors, hospitals, and providers contracted with an insurance company.

In-Network – Providers who have negotiated rates with the insurance company.

Out-of-Network – Providers without a contract with the insurer, usually resulting in higher costs.

Primary Care Physician (PCP) – The main doctor who coordinates a patient’s care and referrals.

Referral – Approval from a PCP to see a specialist.

Open Enrollment – The annual period when people can enroll in or change health insurance.

Special Enrollment Period (SEP) – A limited window outside open enrollment triggered by qualifying life events (marriage, birth, loss of coverage).

Qualifying Life Event – A life change that allows someone to enroll or change plans outside open enrollment.