Frequently Asked Questions About

Individual Health Insurance

What is individual health insurance?

Individual health insurance refers to health insurance coverage that is specifically designed for individuals and families, as opposed to being provided through employer groups or organizations. Individual health insurance offers a variety of affordable individual and family health insurance options, so you can find a healthcare plan tailored to your needs.

What is a PPO plan?

A Preferred Provider Organization (PPO) is a type of health plan that collaborates with medical providers, including hospitals and doctors, to establish a network of participating providers. By utilizing providers within the plan’s network, you can benefit from cost savings. It’s important to note that seeking medical assistance outside the network may result in additional charges.

What is an HMO plan?

Health Maintenance Organizations (HMO) typically give members lower out-of-pocket health care expenses but also offer less flexibility in the choice of physicians or hospitals 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.

What is a POS plan?

A Point of Service (POS) 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. Similar to HMOs, POS plans typically offer coverage for preventive care visits.

However, you can 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’ll likely have to pay up-front and submit a claim to the insurance company yourself. It is important to note that this may vary by insurance company.

What is the difference between and in-network and out-of-network provider?

In-network-providers are medical professionals and facilities that must meet specific criteria and agree to a reduced rate for covered services under the health plan to be included in the network.

If a doctor or facility has no contract with your health plan, they’re considered out-of-network and can charge you full price. It’s usually much higher than the in-network discounted rate.

Why does out-of-network healthcare cost more?

  • You could be paying for the full price. When health insurers lack a contracted relationship with out-of-network doctors and facilities, they have limited control over the charges for services. As a result, rates may surpass the discounted in-network rate, potentially leading to higher costs for individuals.
  • You might be paying for remaining balance. You could be required to cover the remaining balance if your doctor’s bill exceeds the coverage provided by your plan. Numerous health plans specify a maximum amount they will reimburse for out-of-network services. If the doctor or facility charges exceed this limit, you may be held accountable for the difference, in addition to your deductible, copay, and/or coinsurance.
  • There is a difference in your cost share. When utilizing out-of-network doctors or facilities, copays are not applicable. However, you will still be responsible for paying coinsurance. It’s important to note that this coinsurance amount may be significantly higher than the copay or coinsurance amount for in-network providers.

What is a copay?

A copay is a designated fee that your health insurance plan may necessitate for a particular medical service or supply.

For example, your health insurance plan may require a $20 copay for an your doctor’s visit or a brand-name prescription drug, while your insurance company typically covers the remaining charges.

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 copayments or deductible.

For example, suppose your health insurance plan mandates a 20% coinsurance, without any extra copayment or deductible. In this scenario, a $100 medical bill would necessitate your payment of $20, while the insurance company would cover the remaining $80.

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