The Lazy Girl’s Guide to Understanding Health Insurance


You realize all of those really vital skills you need to have learned in highschool but never did? We’re talking about filing taxes, learn how to change a tire, and learn how to make a budget; actual life skills that the majority of us will use far more often than y=mx+b. Perhaps one of the vital vital topics that was left off of the curriculum was understanding a little bit thing called medical health insurance. When you feel such as you’re way behind on this topic, you’ve come to the appropriate place. Here’s your guide to understanding common medical health insurance phrases, where to get medical health insurance, and a few vital things to recollect on the subject of using your advantages.


Terms You Should Know


What’s a deductible?

Your deductible is the amount of cash you’ll have to pay out of pocket within the 12 months before the insurance advantages kick in. Consider your deductible because the points you may have to rack up before you receive your next Abercrombie & Fitch reward. You spend x amount of dollars to get money off in your next purchase!

Your deductible will be anywhere from $0-$8,000, but in lots of cases shall be within the $1,500-$4,500 range. To satisfy your deductible, you’ll use your medical health insurance card at doctor’s visits, to fill prescriptions, etc. You’ll then receive a bill out of your doctor and what’s referred to as an Explanation of Advantages (or EOB) out of your insurance carrier. It will show you that the claim out of your visit was processed through the insurance and your payment went toward your deductible. Not quite as exciting as receiving your A&F package but still a positive nonetheless!


What’s coinsurance?

When you meet your deductible, the insurance advantages begin. That is the share the insurance can pay toward a claim. This amount is usually between 50-100%. Let’s say your coinsurance is 70%. Which means, after you meet your deductible, the insurance plan can pay 70% of the claims that are available in for covered services and you’ll pay 30%. For instance, if you may have a covered claim that’s $100, the insurance can pay $70, and also you shall be chargeable for $30. Isn’t it great having someone help out for a change?


What’s a copay?

A copay, or copayment, is a preselected amount that you’ll pay for certain advantages. Normally, you may have a copay for pharmaceuticals, doctor’s office visits, and urgent care visits on the time of the visit.

Prescribed drugs generally fall under 3-4 tiers, starting from generic (or tier 1) drugs to specialty (tier 3 or 4) drugs. Chances are you’ll see prescription drug tiers equivalent to $10/$65/$95/$200 or some variation of that.

Office and urgent care visits often even have set copayment amounts that you simply pay upfront. Chances are you’ll see $25 or $50 for office visits and $75 or $100 for urgent care. 

Note: Not all medical health insurance plans utilize copayments. On this case, there is not going to necessarily be a set flat fee, and you’ll pay regardless of the drug or office visit costs (bummer, we all know).


What’s an out-of-pocket maximum?

Your out-of-pocket maximum (OOP)  is the best amount of cash you can pay for covered services under your health plan for the 12 months. When you reach your OOP, you possibly can consider the remaining of your medical health insurance advantages as “free” for the remaining of the 12 months. 

The out-of-pocket maximum will generally include the deductible you previously met in addition to any copays, but this will vary depending in your plan. From the instance above, if coinsurance pays the $70, the $30 that you simply paid would go toward your out-of-pocket maximum. When you’ve reached your out-of-pocket maximum for the 12 months, all covered services going forward must be covered by insurance—completely, this time.


What are preventive advantages?

A majority of medical health insurance plans are mandated by the Inexpensive Care Act, meaning they are going to follow ACA guidelines for preventive advantages. These are the coveted services you generally get once per 12 months, freed from charge. Common preventive advantages include routine vaccinations, blood pressure screenings, cholesterol screenings, and more. You realize, every part it’s worthwhile to stay in tip-top shape. 

Preventive advantages are sometimes split up between demographic groups. There shall be certain advantages specifically for ladies, children, or all adults. Some advantages, equivalent to colonoscopies, require you to be a certain age to ensure that the profit to be considered preventive. 

For a full list of preventive advantages, click here.



The Logistics


Where can I get medical health insurance?

Congratulations, you’re finally a real adult! Translation? You only turned 26 and are getting kicked off your parent’s medical health insurance plan. Now the actual fun begins. 

When this time comes, probably the most straightforward (and customarily most inexpensive) option to obtain medical health insurance is thru your employer. Many employers can pay a portion of your monthly premiums, contribute to a Health Savings Account for you, or (in case you’re really lucky) offer free medical health insurance. 

When you’re in the unfortunate minority and might’t get insurance through an employer, you generally can enroll on a policy through the Marketplace/Exchange. All you may have to do is meet all of the necessities, have the ability to afford it, sell your soul, and sign away your firstborn. Kidding! 

So long as you meet all of the necessities, you possibly can enroll in a marketplace plan on your individual online, or you possibly can reach out to a person medical health insurance broker for assistance.


When can I apply for medical health insurance?

You’re going to need to get your insurance through an employer. If you begin a latest job, you’ll generally need to undergo a “waiting period” where it’s essential to work for the corporate for a set period of time before you qualify to enroll on their insurance plan—this is often anywhere from 0-90 days.

When you don’t enroll as a “latest hire,” meaning inside your waiting period, there could also be limitations to when you possibly can. Typically, you’ll need a Qualifying Life Event to occur, aka a giant life-changing event like losing coverage elsewhere (example: maturity/turning 26), getting married, having a baby, and more

Generally, the one other time to enroll on an organization’s medical health insurance plan is during their open enrollment period. Most corporations renew their medical health insurance plans on Jan. 1, making their open enrollment period the month of December. That is the time period when employees who previously waived (or didn’t elect) the group medical health insurance plan are once more eligible and might enroll for a Jan. 1 effective date. 

There are some cases when the insurance policy renews at a special time, making the open enrollment period different. Do your due diligence and check along with your employer before taking our word as gospel. 

When you are usually not looking for insurance through an employer and are a person or marketplace policy, you’ll likely need to wait for the annual open enrollment period or have a qualifying life event as well.


How much does medical health insurance cost?

Great query! We’d like to let you know, however the only answer here is that there isn’t any one answer. Normally, probably the most inexpensive option is enrolling in a plan through your employer. Generally, the employer can pay a portion of your monthly premium. Your “premium” is the worth you pay, generally monthly, to be enrolled on an insurance plan and have insurance advantages. 

To not be the bearer of bad news, but in case you’re needing a person medical health insurance plan, you’ll likely be chargeable for paying your complete monthly premium yourself. Based in your demographics and the richness of the advantages you select, this might range from $100-$400 monthly. Use those preventive advantages to remain as healthy as possible and keep costs down!


Things to Note

For some more excellent news, it’s vital to do not forget that insurance doesn’t cover all medical procedures, as there are exclusions. Exclusions shall be things like dental services, cosmetic procedures, alternative medicine, etc. 

There’s also a fun little thing called “pre-authorization” that the insurance company will often require before a significant procedure. Which means your doctor must pre-authorize, or prove to the insurance company that the procedure is “medically vital,” before they comply with cover the claim. That is something your provider’s office should concentrate on, but we recommend trusting nobody and taking it upon yourself to be sure that this gets taken care of prematurely.

One other thing to notice is that deductibles, coinsurances, and out-of-pocket maximums are generally reset yearly. In lots of cases, it will occur on Jan. 1 every year, but there will be some variations. 

Pro tip: When you are needing a service that can cause you to hit your deductible, schedule it toward the start of the 12 months, or right after your plan resets, so your insurance advantages kick in and insurance pays a portion or all covered claims for the remaining of the 12 months. We DO NOT recommend taking this recommendation for anything that’s life-threatening, after all.

If you may have any questions regarding your medical health insurance advantages, what’s covered, or what you owe for covered services, bite the bullet and get in touch with your medical health insurance company. Yes, you’ll likely need to wait on hold for an hour, but most corporations now at the least have the choice for you to go away a message and receive a callback. That is certainly one of those times it should be price it to place in a little bit extra work, we promise


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* This can be a summary only. Please contact your medical health insurance provider or an insurance skilled for specific details. 


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