Health Insurance Marketplace: Part 3
Insurance Vocabulary
Welcome back! I hope this blog is providing helpful information for people living with cancer. In this post, I want to continue our discussion into the Health Insurance Marketplace (Marketplace), focusing on insurance vocabulary.
If you live in a state that offers health insurance through the Marketplace, check out their link https://www.healthcare.gov/choose-a-plan/comparing-plans/
You can find more information on the Marketplace at www.healthcare.gov or by calling 1-800-318-2596. They even have a blog at www.healthcare.gov/blog
If you live in California, Colorado, Connecticut, District of Columbia, Idaho, Maryland, Massachusetts, Minnesota, Nevada, New York, Rhode Island, Vermont, or Washington, use this link to find your state’s website for health insurance. As of 9/13/20, PA & NJ residents will no longer purchase health insurance plans at www.healthcare.gov
Before jumping into plan comparisons, I would like to take some time to discuss insurance “vocabulary”. There are four financial terms that you need to consider upfront:
- Monthly Premium: The amount of money you need to spend to continue health insurance coverage for the month.
- Deductible: The amount of money you need to spend for “covered health services” before your insurance company pays for anything. Free preventative services are the exception here. Keep in mind that deductibles must be met each year (usually calendar year).
- Copayments (Copays)/Coinsurance: The amount of money you will need to spend each time you receive a medical service after you have met your deductible.
- Out of pocket maximum: The most money you need to spend on “covered services” in a year. After you pay this total, the insurance company pays 100% for covered services.
More terms to consider are:
- In-Network: This refers to healthcare providers who have contracted with the insurance company to provide member services at an agreed cost. If you select a health insurance plan that pays for services only by an “In-Network” provider, you will want to ensure that your cancer treatment team is part of the insurance plan network. You can either ask your cancer treatment provider if they are an “In-Network” provider, or you can review the provider directory which is found in the details of each plan prior to purchase.
- Out of Network: This refers to healthcare providers who have not contracted with the insurance company to provide member services at the same agreed cost as the “In-Network” provider. This can be confusing, as many health care providers “participate” in many health insurance plans. That does not mean they are “in-Network.” If you receive services from an out-of-network provider, you may have to pay the full cost of the benefits and services you get from that provider, except for emergency services.
Even more terms to consider for the types of health insurance plans:
- HMO: Health Maintenance Organizations– Often HMO plans pay for healthcare services that you receive from an “In-Network” healthcare provider. You will need to select a primary care provider (typically a family practice provider) and obtain referrals for cancer treatment services. This may be a good option if all providers in your cancer treatment team are “In-Network”, as the monthly premiums are lower than other plans. However, you may need to pay the entire cost of service if you receive services from an “Out of Network” provider. Emergency services are typically the exception.
- EPO: Exclusive Provider Organizations- Similar to HMO plans, EPOs limit coverage to care from providers in the EPO’s network (except in an emergency). There may be more providers in their network than in the HMO plan network. Often EPO plans do not cover services provided by “Out of Network” providers. Typically, the monthly premium payment for EPO plans is higher than HMO plans, but lower than PPO plans.
- POS: Point of Service- These plans are a hybrid of HMO & PPO plans. They are not often available on the Marketplace but may be a good option for you if most of your cancer treatment team is “In-Network,” but not all. You will need to select a primary care provider and obtain referrals for cancer treatment services. These plans will provide some coverage for “Out of Network” services, but you may need to pay upfront and then submit paperwork to the insurance company to receive reimbursement. The percentage of coverage for “Out of Network” providers may vary. The co-pays and deductibles on these plans may be higher than you expect.
- PPO: Preferred Provider Organizations: If you choose a PPO, services from “In-Network” and “Out of Network” providers will be covered but at different levels. You will pay higher co-pays if you receive services from an “Out of Network” provider. You are not required to select a primary care provider, nor do you need referrals for your cancer treatment. These plans may have a higher monthly premium but offer increased flexibility. Services from “In-Network” out of state provider may also be covered. Check the out of pocket maximum for these plans.
Depending on the region and state that you live in, your options will vary. Insurance plans are tiered according to coverage and premiums: Platinum, Gold, Silver, Bronze. Cost sharing reduction options may be available.
My next post will move us though the next steps. I hope this information is helpful. If you would like to continue this conversation, please click on the Subscribe button at the top of the Blog page. I would love to hear your comments as well as resources that have worked for you. Please share this information with your family and friends.
Keeping you in my prayers,
Jackie