Frequently Asked Questions
Get Answers to your top questions about getting coverage
Most frequent questions and answers
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.
When possible, most people would prefer to have their employer provide group health insurance coverage. But, if this is not an option for you, it is still important for you to seek coverage. You may be pleasantly surprised with the variety and affordability of the individual and family health insurance options available.
Under the Affordable Care Act (ACA), you normally need to apply for your individual or family health coverage during the Open Enrollment Period (OEP). OEP is a period of time in which you can enroll for health insurance without experiencing a life event that qualifies you for a Special Enrollment Period (see below for more information). The OEP usually begins in November and last for a period of thirty to forty-five days prior to the year the plan is to become effective. For example, if you wish to enroll in health plan starting in 2020, then the OEP would be in November and December of 2019.
You may qualify for a Special Enrollment Period (SEP). You qualify for an SEP if you experience certain life events, such as marriage, birth or adoption of a child, or a change in employment.
There are other types of health insurance plans that are not a part of the ACA and their enrollment period maybe any time throughout the year.
Individual and family health insurance plans are usually described as either “indemnity” or “managed-care” plans. Put broadly, the major differences concern choice of health care providers, out-of-pocket costs, and how bills are paid.
Typically, indemnity plans offer a broader selection of health care providers than managed-care plans. Indemnity plans pay their share of the costs for covered services only after they receive a bill (which means that you may have to pay up front and then obtain reimbursement from your health insurance company).
There are several different types of managed-care health insurance plans. These include HMO, PPO, and POS plans. Managed-care plans typically use health care provider networks. Health care providers within a network agree to perform services for managed-care plan patients at pre-negotiated rates and will usually submit the claim to the insurance company for you.
In general, you’ll have less paperwork and lower out-of-pocket costs with a managed-care health insurance plan, and you’ll have a broader choice of health care providers with an indemnity plan.
As a member of a PPO (Preferred Provider Organization) plan, you will be encouraged to use the insurance company’s network of preferred doctors and hospitals. These health care providers have been contracted to provide services to the plan’s members at a discounted rate. You typically won’t be required to pick a primary care physician but will be able to see doctors and specialists within the network at your own discretion.
You will probably have an annual deductible to pay before the insurance company starts covering your medical bills. You may also have a copayment for certain services or be required to cover a certain percentage of the total charges for your medical bills.
With a PPO plan, services rendered by an out-of-network physician are typically covered at a lower percentage than services rendered by a network physician.
Though there are many variations, HMO (Health Maintenance Organization) plans typically give members lower out-of-pocket health care 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 health care 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 health care services than you would through another type of plan. You may not be required to pay a deductible before coverage starts and your copayments could 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 at all for services rendered by non-network providers or for services rendered without a proper referral from your PCP.
A POS (Point of Service) plan combines some of the features offered by HMO and PPO plans. As with an HMO, members of a POS plan may be required to choose a primary care physician (PCP) from the plan’s network of providers. Services rendered by your PCP may or may not be subject to a deductible. Also, like HMOs, POS plans typically offer coverage for preventive care visits.
Typically, however, you will receive a higher level of coverage for services rendered or referred by your PCP. Services rendered by a non-network provider may be subject to a deductible and will likely be covered at a lower level. If services are rendered outside of the network, you will likely have to pay up-front and submit a claim to the insurance company yourself.
Please note this information may vary by insurance company.
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 can see whichever 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 can 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 health care 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.
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 for certain services.
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.
A copayment or “copay” 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 $15 copayment for an office visit or brand-name prescription drug, after which the insurance company often pays the remainder of the charges.
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 copayments or deductible.
For example, if your health insurance plan has a 20% coinsurance requirement (and does not have any additional copayment or deductible requirements), then a $100 medical bill would cost you $20, and the insurance company would pay the remaining $80.
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.
Medicare is a federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant). Medicare typically covers the costs of hospital, emergency, medical and preventative care. Medicare is funded by the federal government, but various related programs, like Medicare Supplements and Medicare Advantage Plans, have state and federal oversight. The two main categories of Medicare coverage include Original Medicare (with optional Medicare Supplement and prescription drug insurance) and Medicare Advantage.
There are three groups who qualify to receive Medicare:
People who are 65 and older.
People under 65 years old who are disabled and who have been receiving Social Security Disability benefits for at least 24 months.
Qualified people with End Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis, also known as ALS or Lou Gehrig’s disease.
A wide variety of healthcare services are covered by Medicare, depending on the type of policy you choose, including: Ambulance services, Anesthesia, Artificial eyes & limbs, Bariatric surgery, Blood processing & handling, Cardiac rehabilitation programs, Cardiovascular disease screenings, Cervical & vaginal cancer screenings, Chemotherapy, Depression screenings, Diabetes prevention programs, Diagnostic tests (laboratory and non-lab), Eye exams (routine) Eyeglasses & contact lenses, Flu shots, Foot care, Hearing aids, Hepatitis B and HIV screenings, Inpatient hospital care, Kidney transplants, Lung cancer, screenings, Mammograms, Mental health care (inpatient and outpatient), Occupational therapy, Opioid use disorder treatment services, Organ transplants, Pain management, Prescription drugs (outpatient), Preventive & screening services, Radiation therapy, Sexually transmitted infections screenings & counseling, Sleep studies, Surgery, Urgently needed care, X-rays, Yearly “wellness” visits, Fitness Club Memberships, Over the Counter Allowance and Telemedicine.
Many people automatically get Original Medicare – also known as Part A and Part B – especially if they’re receiving Social Security retirement benefits when becoming eligible for Medicare coverage. Other people may need to sign up for Medicare. If you’re aging into Medicare, you have a seven-month Initial Enrollment Period (IEP) to apply for Medicare: three months before you turn 65, the month you turn 65, and three months after you turn 65. And you must sign up individually for the parts of the program – Parts A, B, C and/or D – that you want.
It depends. You may need Medicare even if you already have other health insurance coverage, or if your current plan doesn’t meet the minimum coverage requirements. Most plans that employers offer meet these standards. So, if you have insurance through your job, you probably don’t need Medicare. However, by staying on an employer plan, you can delay enrolling in Part B without a penalty and avoid paying Part B premiums. An important note: When you have Medicare plus additional insurance policies, each provider becomes a “payer.” The policy that pays for your specific medical services first depends on the coordination of benefits rules for your plans. In other words, the primary payer will pay what it owes on your medical bills first, then the provider will send the remaining amount to the secondary payer to pay the rest.
Medicare is divided into two categories, with Medicare Part D as an additional option for prescription coverage. When signing up for Medicare, Part A is mandatory, but Parts B, C, and D are optional. But keep in mind that you will incur a late penalty if you don’t enroll in Parts B and D when you’re first eligible. Here’s a breakdown of the different Medicare parts and plans:
Part A (Original Medicare Plan)
Covers inpatient care in a hospital, inpatient care in a skilled nursing facility (not custodial or long-term care), hospice care, skilled nursing home care, and other types of home health care.
Part B (Original Medicare Plan)
Covers medically necessary services, preventative care, clinical research, mental health care, inpatient and outpatient services, partial hospitalization, and more.
Part C (Medicare Advantage Plan)
Combines Parts A and B into bundled coverage through an approved private insurance company that uses the Medicare network.
Part D (Prescription Drug Coverage)
Pays for several tiers of name brand and generic medications, sometimes up to a limit.
Medicare Supplement Insurance
Extra coverage through an approved private insurance company that fills gaps or “supplements” what Original Medicare doesn’t cover. Also known as a Medigap plan. You can typically buy Medigap insurance online to help you cover the out-of-pocket costs and additional services that are not covered by your primary plan As examples, a Medicare supplement plan may be used to cover copays, coinsurance fees, and deductibles. A Medicare supplement plan is a standalone policy, so you’ll pay an additional cost for the plan outside of your primary Medicare premium. You must also have Medicare Part A and Part B to qualify for Medigap insurance. Lastly, Medigap policies are guaranteed renewable, which means your insurance company can’t cancel your policy if your health conditions change. You just have to pay your premiums on time.
Not usually. Original Medicare (Parts A and B) plans don’t cover most dental services or vision care. But if you’re already in the hospital, some dental or vision services may be covered.Certain Medicare Advantage Plans (Part C) may cover dental and vision services, so make sure to check your policy before you enroll.
In many cases, yes. Medicaid is a federally supported program that helps states provide medical coverage for individuals with a limited income. So you may qualify for both if you meet the economic requirements for Medicaid and the age or disability requirements for Medicare. Some states also provide expanded Medicaid access to individuals (including those with Medicare) who meet economic qualifications after subtracting their out-of-pocket medical expenses from their income. Note: If you qualify for both programs, Medicare is automatically designated as your primary insurance provider while Medicaid becomes the secondary payer.
Medicare Part D coverage varies based on your insurance company, but all plans must include a minimum amount of medication coverage that’s approved by Medicare. So qualifying Part D plans must offer at least two medication options from each class of drug category on their formulary to treat common health issues. Check your insurance company’s formulary (a list of generic and brand name prescription drugs covered by your specific health plan) to see what prescription drugs are covered.
TrOOP includes the amount of your Initial Deductible (if any) and your co-payments or co-insurance during the Initial Coverage stage. While in the Donut Hole, it includes what you pay when you fill a prescription and of the 75% Donut Hole discount on brand-name drugs, it includes the 70% Donut Hole Discount paid by the drug manufacturer. The additional 5% Donut Hole discount on brand-name drugs and the 75% Donut Hole discount on generics do not count toward TrOOP as they are paid by your Medicare Part D plan. TrOOP also includes payments made for your drugs by any of the following programs or organizations: “Extra Help” from Medicare; Indian Health Service; AIDS drug assistance programs; most charities; and most State Pharmaceutical Assistance Programs (SPAPs).
If you are a Medicare beneficiary who takes prescription drugs, you may have heard of the Part D coverage gap. Medicare plans that include prescription drug coverage generally cover your medications until you and your plan have spent up to a certain limit on covered prescription drugs in one year. Once the total of your costs and Medicare’s spending has reached that limit, your Medicare plan pays less for your prescription drugs, while you pay a higher share of your medication costs. This temporary coverage change is called a “coverage gap” (also called the “donut hole”). A combination of government subsidies and manufacturer discounts will gradually reduce out-of-pocket costs for covered medications to close the gap by 2020. Medicare prescription drug coverage is available through either a stand-alone Medicare Part D Prescription Drug Plan (which works with Original Medicare), or through a Medicare Advantage Prescription Drug Plan. Both types of plans are available through Medicare-approved private insurance companies.
In 2020 the Coverage Gap or (Donut Hole) works like this, when you and your Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan together have paid a total of $4,020 on covered prescription drugs, the coverage gap starts. Costs like your yearly deductible (if your plan has one), copayments, and/or coinsurance costs count towards this limit. In addition, keep in mind that only costs spent by you and your plan on medications in your plan’s formulary, or list of covered drugs, count towards the initial coverage limit. The formulary may change at any time, but your Medicare plan will notify you if necessary. You then pay up to 25% of your Medicare plan’s cost for generic drugs during the coverage gap. For covered brand-name drugs, you will pay no more than 25% of your Medicare plan’s cost. If your out-of-pocket expenses for covered prescription drugs reach $6,350, you’re out of the coverage gap and you enter the “catastrophic” phase of Medicare prescription drug coverage. If you reach this phase, you will only have to pay a small copayment or coinsurance for covered medications for the rest of the year.
Keep in mind that your plan premium, the pharmacy dispensing fee, and money you spend on medications that are not covered on your plan’s formulary do not count towards the catastrophic coverage threshold and getting you out of the coverage gap.
Medicare prescription drug coverage resets each year. On January 1 of each year, you begin with your plan’s initial prescription drug coverage and its associated deductible and cost-sharing requirements (if there is a deductible). If you were in the coverage gap in December of the year before, you would return to the plan’s initial coverage on January 1, where you pay a copayment or coinsurance for covered prescription drugs after the plan’s deductible is met (assuming the plan has a deductible).
Now that you have a better understanding of what your costs may be if you enter the coverage gap, you may be wondering if there’s anything you can do to avoid entering it in the first place. Keep in mind that not every beneficiary will enter the coverage gap. Whether you do depends largely on the prescription drugs you take, how often, how much they cost, and your specific Medicare Part D coverage. However, there are some things you can do to help lower your out-of-pocket costs and reduce your chances of entering the coverage gap:
- Switch to generics, if available. In general, brand-name drugs tend to be more expensive than generic drugs. If you currently take a lot of brand-name medications, ask your doctor if a generic equivalent is available that might be equally effective for treating your condition.
- Find out if your plan offers extra coverage in the coverage gap. If you do enter the coverage gap, some Medicare plans that include prescription drug benefits offer extra coverage to further reduce out-of-pocket costs in the coverage gap. Contact your Medicare plan to find out if this is available.
- Purchase your medications from a mail-order pharmacy. Some Medicare plans have mail-order pharmacy programs that may offer lower cost sharing when you purchase a larger amount of your prescription drugs. If there are certain medications you take over a longer period, you may be able to pay lower copayments when you get a larger supply through these programs. For example, the copayments for a three-month supply may be cheaper than getting a 30-day supply. Check with your Medicare Prescription Drug Plan or Medicare Advantage plan for more information.
- See if you are eligible for help with prescription drug costs. If you qualify for the Extra Help (or Low-Income Subsidy) program, you can get help with certain Medicare Part D costs, such as premiums, copayments, and deductibles. Extra Help is a Medicaid program that helps low-income beneficiaries with certain prescription drug costs; if you’re eligible for this program, you won’t enter the coverage gap. In addition, some states have State Pharmaceutical Assistance Programs that help low-income beneficiaries with plan premiums and other expenses. Find out if your state has a program and if you are eligible.