Individual Health Insurance FAQ

In simple terms, health insurance is an agreement between you and a health insurance company. When you enroll in a health plan, the insurance company agrees to pay for certain health care services, like preventive care and other covered medical services.

There are four common types of health insurance plans: HMOs, PPOs, EPOs, and POS plans. The right plan for you will depend entirely on your specific financial and health care needs.

If you expect to have a large amount of medical care rather than just preventive services, the best type of plan for you might have lower out-of-pocket costs with a higher monthly payment.

If you are healthy and do not expect to need care outside of preventive visits, a plan with a higher deductible and lower monthly payment could help save money while still providing the coverage you need.

The Lawrence D. Share Company can explain the differences between these types of plans and help you determine which one is right for your needs and budget. 

November 1 – Open Enrollment begins. This is the first day to enroll or change your insurance plan for the upcoming year.

December 15 -  The last day to enroll in a health plan for coverage that starts in January of the upcoming year.

January 1 – If you have enrolled by December 15 of the previous year, this is when your new coverage starts.

January 15 - This is the last day to sign up for a new health plan under the Open Enrollment Period.

February 1 – If you enroll between December 16 and January 15, this is when your coverage for the new plan year will start.

Premium
The amount you pay monthly to your health insurance company for health insurance coverage. If you have a Marketplace plan, you may be able to lower your costs with a premium tax credit (subsidy).

Deductible
The amount you must pay each year for certain covered health care services before your insurance starts to pay. Once your deductible is paid in full, you usually only pay a copay or coinsurance for a covered service. Typically, a higher deductible means you will have a lower premium. A lower deductible often means you will have a higher premium. Some plans have no deductible associated with certain services, meaning those services are covered by your insurance right away.

Co-pay
A flat fee that you may pay for covered services when you go to an in-network doctor or hospital covered by your plan. Often, you will have different co-pays for various types of care and prescriptions. Some plans require your deductible to be paid first before you pay co-pays. Some plans have $0 co-pays for certain services, such as office visits. You could be eligible for reduced co-pays on your plan, based on your income.

Co-insurance
A percentage amount you pay for certain covered services after your deductible has been met. For example, if you have 20% coinsurance, you are responsible for paying 20% toward the covered services, up to a certain amount, while your health insurance company covers 80%.

Out-of-pocket maximum
The most you will pay each year for services covered by your health care plan. This maximum includes payments you make for covered services like deductibles, co-pays, and co-insurance.  It does not include your premium costs or any payments for services not covered by your plan. Once your out-of-pocket maximum has been reached, your insurance plan will pay 100% of covered medical services for the rest of the year.