A deductible is the amount that you have to pay for your health care each year before your insurance starts paying for your care. Similar to car insurance, many health plans require you pay a certain amount out-of-pocket before the coverage kicks in. For example, if you have a deductible of $1500 you have to pay the first $1500 of your medical costs before your insurance starts paying. In some plans the deductible applies only to services that you get outside of the provider network. Also, some plans have a separate deductible for prescription medications. Usual deductible does not apply for preventive services.
The money that you pay out-of-pocket for the services that you receive. This could include anything from an office visit to the doctor, prescription medicine, an x-ray, or even a hospital stay.
Now if the money you pay is a set amount that would be called a co-payment or a copay. If the money that you pay is a percentage of the cost then that would be called coinsurance. Now depending on the plan that you have it dictates whether you have a co-payment/copay or coinsurance.
Health insurance is divided into four main categories. Each category has the name of a metal, the more expensive the metal the more expensive the premium but the richer the benefits. Bronze for example covers 60% of your medical expenses it is also the least expensive premium. Silver covers 70%, Gold covers 80% and Platinum, the most expensive tier, covers 90%.
A health insurance premium is the amount of money you pay per month to the health insurance carrier. Now, you either pay by the month of you pay it per pay period depending if you get it through your employer or not.
If you get it through your employer, your employer most likely covers a portion of your premium.
If you get your insurance through either Covered California or through the exchange in another state then you most likely get an Advance Premium Tax Credit, that's where the Federal Government pays a part of your health insurance premium for you.
If you are not on the exchange and you buy directly through the carrier then you're paying 100% of the premium yourself.
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HMO - Health Maintenance Organization
An HMO is a type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. You will usually need a referral from your Primary Care Physician to see a Specialist, resulting in multiple co-pays. All healthcare services are managed in-network through your Primary Care Physician.
In California, the popular HMOs are Kaiser Permanente, Sutter Health Plus, Western Health Advantage, Health Net of California, Sharp Health Plan, LA Care, Molina Healthcare, and Valley Health Plan.
PPO - Preferred Provider Organization
A PPO is a type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost. PPOs do not require you to select a Primary Care Physician. One of the benefits of a PPO is you usually can self-refer to a Specialist.
In California, the popular PPOs are Blue Shield of California, Health Net Life Insurance Company, and Oscar.
EPO - Exclusive Provider Organization
A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency). Under an EPO plan you do not choose a Primary Care Physician. You can receive care from any of the in-network doctors and self-refer to in-network specialists.
In California, the popular EPOs are Anthem Blue Cross, Health Net Life Insurance Company, and Oscar.
If you want to discuss options about your health insurance, we recommend speaking with an independent insurance agent like George Beach Insurance Services. We work for you the client, and not a particular big company.