wHAT iS wHAT iN hEALTH iNSURANCE !!

What is individual and family health insurance?
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 (often called group insurance).

What kinds of individual and family insurance plans are 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 healthcare providers, out-of-pocket costs and how bills are paid. Typically, indemnity plans reimburse you for your medical expenses regardless of who provides the service, although in some cases your reimbursement amount may be limited.

There are three basic types of managed care plans: (1) Health Maintenance Organizations (HMOs), (2) Preferred Provider Organizations (PPOs), and (3) Point of Service (POS) plans. Although there are important differences between the different types of managed care plans, there are similarities as well. All managed care plans involve an arrangement between the insurer and a selected network of health care
providers (doctors, hospitals, etc.). All offer policyholders significant financial incentives to use the providers in that network. There are usually specific standards for selecting providers and formal steps to ensure that quality care is delivered.

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



What is a PPO?
A PPO is made up of doctors and/or hospitals that provide medical service only to a specific group or association. Rather than prepaying for medical care, PPO members pay for services as they are rendered. The PPO sponsor (usually an employer or insurance company) generally reimburses the member for the cost of the treatment, less any co-payment. In some cases, the physician may submit the bill directly to the
insurance company for payment. The insurer then pays the covered amount directly to the healthcare provider, and the member pays his or her co-payment amount. The price for each type of service is negotiated in advance by the healthcare providers and the PPO sponsor(s).


What is an HMO?
Though there are many variations, HMO (Health Maintenance Organizations) plans typically enable members to have lower out-of-pocket healthcare 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 healthcare 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 healthcare services than you would through another type of plan. You may not be required to pay a deductible before coverage starts and your co-payments will likely 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 whatsoever for services rendered by non-network providers or for services rendered without a proper referral from your PCP.




What is a POS?
A point of service plan is a type of managed healthcare system where you pay no deductible and usually only a minimal co-payment when you use a healthcare provider within your network. You also must choose a primary care physician who is responsible for all referrals within the POS network. If you choose to go outside of the network for healthcare, you will likely be subject to a deductible (around $300 for an individual or $600 for a family), and your co-payment will be a substantial percentage of the physician's charges (usually 30-40%).


What is an Indemnity Plan?
A traditional Indemnity plan offers a great deal of freedom in choosing which doctors and hospitals to use, but will probably involve higher out-of-pocket costs and more paperwork.


Under an Indemnity plan, you may see whatever doctors or specialists you like, with no referrals required. Though you may choose to get the majority of your basic care from a single doctor, your insurance company will not require you to choose a primary care physician.


However, this kind of freedom will cost you. You'll likely be required to pay an annual deductible before the insurance company begins to pay on your claims. Once your deductible has been met, the insurance company will typically pay your claims at a set percentage of the "usual, customary and reasonable (UCR) rate" for the service. The UCR rate is the amount that healthcare providers in your area typically charge for any given service.


An Indemnity plan may also require that you pay up front for services and then submit a claim to the insurance company for reimbursement.




What is an HSA?
Is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a High Deductible Health Plan (HDHP). The funds contributed to the account are not subject to federal income tax at the time of deposit. Funds may be used to pay for qualified medical expenses at any time without federal tax liability.


Withdrawals for non-medical expenses are treated very similarly to those in an IRA account in that they may provide tax advantages if taken after retirement age, and they incur penalties if taken earlier. Not all high-deductible plans are eligible for use in conjunction with an HSA.




What is a co-payment?
A "co-payment" or "co-pay" 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 $35 co-payment for an office visit or $25 for a brand-name prescription drug, after which the insurance company often pays the remainder of the charges.




What is a deductible?
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. 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.





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




What is the difference between in-network and out-of-network providers?
An in-network provider is one contracted with the health insurance company to provide services to plan members for specific pre-negotiated rates. An out-of-network provider is one not contracted with the health insurance plan. Typically, if you visit a physician or other provider within the network, the amount you will be responsible for paying will be less than if you go to an out-of-network provider. Though there are some exceptions, in many cases, the insurance company will either pay less or not pay anything for services you receive from out-of-network providers.
As a general rule, PPO, POS, and HMO plans make use of provider networks. Indemnity plans typically do not.




When can my coverage start?
You can request that your Individual and Family health insurance plan start anytime between 1 and 90 days in the future. However, the insurance companies will typically need some time to process your application so keep in mind that the actual date for the start of your coverage may vary depending on the underwriting process and the availability of your medical records. (Underwriters will receive your application much faster if you "eSign" your application.)




Is it possible to only insure my child?
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 entered in the children field.




If I apply for an insurance plan, am I obligated to buy?
No. You are under no obligation to buy a health insurance plan when applying for health insurance. After submitting your application you may cancel it at any time during the underwriting process. In addition, federal law mandates a 10 day ʻfree lookʼ where you can cancel your policy at an point within the first 10 days of issuance.




Can I contact someone if I need help?
Yes. We believe in providing you with top-quality customer service. Our agents are all fully licensed health insurance agents and knowledgeable representatives, ready to assist you.



Contact information can be found on the Contact Us page.