Health Insurance Basics – How to understand coverage

RF Insurance Masters wants to make sure you understand health insurance basics so when you are choosing a plan, you can make a sound decision. Are you considering COBRA? Are you looking to establish a Group Health Plan for your company and want to know what you need to get one started?

We always recommend working with an insurance agent you feel comfortable with to help provide the advice and guidance you need to select the best plan for your particular situation. We know that there is no one plan that is right for everyone, but we know that we can find the best solution for your particular needs and situations. I wanted to review a few items to help you understand the various features and the basics of the options. learn more about our approach to providing health insurance.

Reading: How to read health insurance coverage

It is important to know that working with an agent can provide very specific information and advice on each plan to offer. There are some elements that everyone should take into account when choosing a health insurance plan. One thing you should know about the purchase of online insurance and when you are seeing a price for a plan and show the monthly premium. The premiums vary according to the deductible, the coast, the co -payment and the maximum disbursement characteristics of the plan. These elements are the basics that you must take into account when buying insurance (it is necessary to review the benefit summary of your particular plan to learn about the plan’s coverage):

  • deductible
  • coinsurance
  • out-of-pocket coinsurance maximum
  • copayments
  • prescription coverage
  • medical and prescription drug maximum
  • lifetime maximum
  • deductible is the out-of-pocket amount to which you will be exposed if you have an accident or illness. this is the first set of medical expenses you are faced with and responsible for paying. these costs are paid by you are the in-network prices that the insurance company negotiated with the provider or the allowed amount. One thing to know is that copays for doctor visits do not count toward your deductible, however, they will count toward your out-of-pocket maximum… for example, if you had a policy that had a $2,500 deductible, this first $2,500 is your responsibility. For families, your family deductible is two or three times this deductible depending on the plan chosen. you should review this in detail with the summary of benefits.

    How do you select the deductible that is best for you? we would review your history to see how much you have spent on claims or medical issues. everyone’s situation is different. if you’re not sure, you can work with an agent to determine what’s best for you. your available cash may cause you to consider different levels of deductibles. The way to save on premiums would be to consider raising your deductible.

    coinsurance is the portion after you meet your deductible that you and the insurance company share for the following set of medical expenses. These coinsurance values ​​come in various configurations, such as 100/0, 90/10, 80/20, 70/30, 60/40, and 50/50. the first number is the percentage that the insurance company pays, the second number is the percentage that you will pay. For example, if you exceeded your deductible by $10 and had an 80/20 coinsurance plan, then you would pay $2 of the $10 in medical expenses, the insurance company would pay $8.


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    out-of-pocket coinsurance maximum is the maximum amount of coinsurance money that you will be responsible for paying in the event of a serious illness or injury. is the limit for which you will be responsible. for an individual it will be this number, and for a family it will be two or three times this amount depending on their plan. check your summary of benefits to see the details of your plan.

    Your total annual exposure for an accident or serious injury is the maximum out-of-pocket coinsurance plus your deductible. for the family it is the limited family added together. after spending this on your medical expenses, the insurance company will pay for any additional medical expenses. this is why you need to have health insurance to limit your medical dollars and protect you from bankruptcy.

    The medical and prescription expense maximum is the total of the deductible, the coinsurance paid by the insured and the copayment that you will pay. this number is your maximum annual liability for the policy. after paying this amount, your insurance company should cover 100% of any additional charges.

    Health Insurance Deductible, Coinsurance and Max Out of Pocket

    Above are two examples you can consider to help understand 80/20, 70/30, 60/40, or 50/50 (the first number is the insurance company’s portion and the second number is your portion (80 % paid by insurer and 20% paid by the insured until reaching the maximum disbursement)) and coinsurance 100/0. the left side to the right is increasing medical spending dollars.

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    copayments are a benefit in some plans that allow you to enter the doctor’s office for a certain price of $25, $30, $35 or $50, for example. some have two copay levels for general practitioners and specialists. Some plans cover lab work, but most lab charges will be billed to you. check your plan details to be sure. these copays do not count toward your annual deductible. Some plans are available without copays, and removing this feature may lower your premium. You may want to consider this if you don’t go to the doctor often. Some plans have unlimited visits and others have limited visits, such as 3, 4, or 6. Check your plan with your agent to understand the limits.

    Annual Wellness/Physical Exams – Now included with individual major medical plans at no cost or as a copay for these benefits. each plan is different, so you’ll need to review the summary of coverage. These physicals will cover blood tests, pap smears, mammograms, colonoscopy, etc. necessary to keep your health under control. this will make wellness more accessible to keep up with your annual physicals.

    prescription drug coverage sometimes comes with the major medical plan. Some plans will offer generic and brand name drugs with no prescription deductible at all, and sometimes there is a $200, $500 or $1000 deductible for brand name drugs, and generic drugs are not subject to a deductible. Some plans don’t offer any coverage until you meet your out-of-pocket deductible and coinsurance maximum. please review your summary of benefits to be sure what coverage you have under your plan. your agent can guide you.

    Lifetime Maximum is the most the plan will pay while you are in the plan. Since health reform went into effect in January 2011, all plans have an annual and lifetime unlimited maximum. this allows there to be no limit on the insurance company’s payment when you have current insurance.

    Now you’re ready to begin your search for the best plan for you. contact us to help and advise you on the best options available to you. just click the free quote button or give us a call.

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    • Our Approach to Finding Affordable Health Insurance: Check out our unique approach to saving on health insurance.
    • cobra: understand cobra and its options/risks
    • group health insurance information