How Health Insurance Works

Health insurance.

Confusing, right?

So many clinical terms and caveats.

Why can’t it just be more straightforward?! you scream as you shake your fist in the air.

Luckily, we know a thing or two about insurance, and we’ll break it down, old-school style, on how health insurance works.

Do I need insurance?

Yes. The U.S. Government says you need it unless you want to pay a penalty ($695 per adult, $347.50 per child and up to $2,085 for a family, or 2.5% of household income if it’s above the tax return filing threshold). But don’t fret, we make it easy to shop for it.

How do I get insurance?

There are several ways you can get insurance:

  1. Through HealthCare.gov
  2. A health insurance broker
  3. By doing research and calling a carrier yourself.
  4. Or, hint hint, through KindHealth.

When can I enroll?

The current enrollment period is November 1st, 2015, through January 31st, 2016. However, if you’re unable to purchase insurance during that time, you may be able to during a “qualifying life event,” such as:

  • Loss of coverage through job change, divorce, death in the family, graduation or falling off parent’s insurance.
  • Change to income
  • Change in immigration status
  • Moving outside of coverage area
  • Getting married
  • Having or adopting a child

What the heck is the Affordable Care Act/the Marketplace?

In 2010, President Obama signed into law the Affordable Care Act, otherwise known as “Obamacare” by the cool kids. Major advances under the Affordable Care Act include:

  1. Ending the practice of denying people health insurance coverage for a preexisting condition.
  2. Enabling people under the age of 26 to get health insurance through their parents’ coverage.
  3. Covering preventative doctor appointments at no cost to the patient.
  4. And many other awesome things you can read here.

Do I have to use HealthCare.gov?

The short answer is no, you do not. Learn more about HealthCare.gov here.

What types of insurance plans are there?

PPO

Preferred Provider Organization (PPO) means you can see any provider or specialist within your network and you don’t need a referral to do so. You also don’t have to select a primary care physician when enrolling. PPOs generally have the most providers out of all plan types.

In other words, you’re a free-range patient.

HMO

Health Maintenance Organization (HMO) means you have to get referrals from your primary care physician in order to see a specialist. You also need to select your primary care physician when enrolling, otherwise the carrier will do it for you. HMOs typically have the least amount of providers out of all plan types. In other words, you’re paying for two doctor visits.

POS

Point of Service (POS) is similar to a PPO. We all know what you’re thinking and no, a POS in this case does not mean that. A POS means you can see any provider or specialist within your network without a referral. You also don’t have to select a primary care physician when enrolling. However, a POS has slightly fewer provider options than a PPO.

EPO

Exclusive Provider Organization (EPO) is similar to a PPO. An EPO means you can see any provider or specialist within your network and you don’t need a referral to do so. You also don’t have to select a primary care physician when enrolling. EPOs have several provider options but not as many as a POS or PPO, and you have no out-of-network benefits.

Can I be denied coverage?

No! Not that long ago, insurance carriers could deny you coverage (lame), but with the passing of the Affordable Care Act, you can no longer be denied. It doesn’t matter if you have or had cancer, heart disease or other chronic illnesses- you can get health insurance!

Am I able to get my family insurance through my plan?

Yes. When you apply for coverage, you can also apply for coverage for your dependents. This includes your spouse, children, and in some cases, your domestic partner. However, the cost will change depending on how many people are added.