Q & A

What is a deductible and how does it work?
What is coinsurance?
What is "out-of-pocket maximum?"
What are co-pays?
Do I have to meet my deductible before insurance will pay when I see my doctor?
What is a network?
What's the difference between a Primary Care Physician (PCP) and a specialist?
What is a pre-existing condition?
Will a pre-existing condition prevent me from obtaining health insurance?
What if I'm currently pregnant?
What is an HMO?
What is a PPO?
What is the main difference between an HMO and a PPO?
What is a Health Savings Account (HSA)?

What is a deductible and how does it work?
Typically, a deductible is the amount of money you must pay each year before your health insurance plan starts to pay for covered medical expenses. After this deductible is met, the insurance company will pay a percentage of the bill, this is called the coinsurance.

What is coinsurance?
Coinsurance is cost-sharing where you are responsible for paying a certain percentage for a covered medical expense and the insurance company will pay the remaining percentage of the covered medical expenses after your deductible is satisfied. For a health insurance plan with 20% coinsurance, once the deductible is met, the insurance company will pay 80% of the covered expenses while you pay the remaining 20% until your out-of-pocket limit is reached for the year. Typically, the out-of-pocket limit is the maximum amount you will pay out of your own pocket for covered medical expenses in a given year.

What is "out-of-pocket maximum?"
This is the amount of money one would pay out of their own pocket towards their medical expenses in any given year. An out-of-pocket expense may refer to how much the co-payment, coinsurance, or deductible is when added together. Also, when the term annual out-of-pocket maximum is used, that is generally referring to how much the insured would have to pay for the whole year out of their pocket, excluding premiums.

What are co-pays?
A co-payment or co-pay is a specific amount you pay for each medical service, such as $30 for an office visit, after which the insurance company pays the remainder of the affiliated charges.

Do I have to meet my deductible before insurance will pay when I see my doctor?
Usually, you do not need to meet your plan deductible when visiting a participating Dr. You may need to meet the deductible before insurance will pay when you see a doctor when accessing care outside of the insurance company network or under a Health Savings Account H.S.A plan.

What is a network?
A network is a list of doctors, hospitals and other providers who have contracted with an insurance company to offer benefits to members for negotiated fees. The providers' fees have been negotiated, which means that the insurance company will not necessarily pay the doctor or hospital what your actual medical bills are, but will pay a lower amount. If you have a health insurance plan that utilizes a network and you use providers who are not part of the network, the amount of money that you would have to pay for those services will be considerably higher than if you use providers who are in the network.

What's the difference between a Primary Care Physician (PCP) and a specialist?
A Primary Care Physician, or PCP, is the doctor you would go to on a regular basis, like when you're simply not feeling well. A specialist is a doctor that your PCP might refer you to if the problem you have requires a doctor with more expertise with that medical problem.

Back to Top

What is a pre-existing condition?
A pre-existing condition is any health condition you have or have had prior to applying for a policy. Some insurance companies want to know about all of your pre-existing conditions. Others may only look back a limited number of years.

Will a pre-existing condition prevent me from obtaining health insurance?
The answer to this question will vary depending on if you are applying for individual insurance vs. employer group coverage. Regarding individual or family policies, some insurance carriers can decline to offer a policy, increase the rate for your specific pre-existing condition or waive coverage for the pre-existing condition. Generally, pre-existing conditions are covered under an employer group plan unless you have had a lapse in coverage of 63 days, or more, in the 12 months prior to enrolling in the employer plan.

What if I'm currently pregnant?
Insurance carriers will not issue an individual plan while you are pregnant.
Being pregnant usually will not exclude you from being covered by an employer group plan.

What is an HMO?
A Health Maintenance Organization (HMO) is a network driven plan. The insurance company offering the HMO contracts with specific doctors, specialists, hospitals, and other providers to offer benefits to HMO members. Usually HMO's require you to choose a primary care physician (PCP) who is contracted by the insurance company to coordinate your care. This may include requiring referrals for specialist care.

What is a PPO?
A Preferred Provider Organization is another form of managed care. A PPO negotiates arrangements with doctors, hospitals and other providers who accept lower fees from the insurer for their services. A PPO offers both in and out of network benefits and does not require member's care to be coordinated by a specific primary care physician, nor do members need referrals to participating providers.

What is the main difference between an HMO and a PPO?
Most HMOs require you to select a specific doctor as your primary care physician, or PCP. This doctor is your first point of contact for most medical conditions, exceptions are made for emergencies. Your choice of specialists and hospitals is usually limited to those already under contract with the HMO, and your primary care physician is the one who generally decides whether or not a referral to a specialist is necessary.

PPOs combine some of the characteristics of HMOs with the flexibility of traditional indemnity plans. PPOs offer a specific set of doctors and hospitals that you may choose from to get discounted rates. These are called "preferred" or "in-network" providers.  PPO members are free to see any in-network provider at any time. Members may also see doctors who are not in the network, but the payment for those doctors will be higher.

What is an Health Savings Account (HSA) / High Deductible Health Plan (HDHP) ?
A Health Saving Account (HSA) Plan allows individuals to put tax-free money into an (HSA) bank account, have it grow tax-free and can be withdrawn tax-free when used toward un reimbursed medical expenses. HSAs are used in conjunction with a "High Deductible Health Plan" (HDHP). Typically, all care is subject to the plan deductible before the insurance pays anything, including primary care, specialist care, and prescription drugs.

Back to Top