Health Insurance Explained – The YouToons Have It Covered

Millions of us now have health insurance underthe Affordable Care Act, or what some people call Obamacare. But like many things in life, your healthinsurance can often be confusing and complicated. Whether you've been insured for years or you'renew to the game, understanding your policy is important to your health…and your wallet. First things first, you have to pay your premiumevery month or your insurance could get cancelled – kind of like your cable subscription. You can also think of it like a shared healthcare piggy bank — we all chip in each month, even if we're healthy, so the money is therewhen we need it.

If you get insurance at work, your employerprobably pays most of your premium and the rest comes out of your paycheck automatically. If you have Medicaid, you most likely don'thave to pay any premium at all — the federal government and your state take care of that. If you're insured through a new health insurancemarketplace, depending on your income, you may be eligible for a tax credit that paysa portion of your premium. Once you have that shiny new insurance card,you'll want to try really hard to keep it in your wallet! To better your odds at staying healthy, besure to take advantage of the free preventive.

Services that all new insurance plans provide. But of course…stuff happens. And that's when insurance really comes inhandy. Now, having insurance helps a lot, but itdoesn't mean all your health care is going to be free. There are lots of details about your insuranceplan that affect how much you pay when you get sick or injured. If you have Medicaid, a lot of these servicescould very well be free. Otherwise, you'll likely have to pay somethingwhen you go to the doctor or fill a prescription.

This is called a copay when it's a specificdollar amount — like $25 per visit…or coinsurance if it's a percentage of the bill. There's also the deductible — that's howmuch comes out of your own pocket before your insurance starts paying. Depending on your plan, you might have a deductiblefor all your care, or it might only apply to some types of care, like hospital staysand prescriptions. So read your plan material, because it canrun into the thousands of dollars! Another important part of your plan is theout of pocket maximum. This is the most you'll ever have to pay inany one year.

At least for the benefits your plan covers. Your insurer will pay 100% of anything beyondthe maximum for the rest of the year. It can be just as confusing dealing with prescriptions! Your plan has a list of drugs it will payfor, called a formulary, but the prices vary. Check with your doctor or pharmacist, becausea generic drug might fix you up the same as a brand name drug, but the price differencecould be huge. So, those are the costs typically involved,but remember that they'll be affected by your insurance plan's provider network. This is a list of doctors and hospitals thatare connected to your plan.

Insurance companies negotiate discounts withthese providers. Stay in-network, and the discounts get passedto you. Go out of network, and you could end up payingfull price. And remember that out-of-pocket limit? It won't work if you go out of network! In some plans — like HMOs or EPOs — yourinsurance would pay nothing if you go out-of-network. In other plans — like PPOs — your insurancewill cover you no matter where you go, but you'll pay a lot more if you go out of network. Also, if you want to visit a specialist – likean orthopedist – some plans require a referral.

From your primary care doctor. Sound easy enough? Well, sometimes staying in-network can betricky! In a hospital, it's possible that your surgeoncould be in-network, while your anesthesiologist is not. Don't be afraid to negotiate with your provideror file an appeal with your insurer. So as you can see, there's a lot to thinkabout when you choose an insurance plan each year. Some plans may have low premiums, but fewerdoctors or hospitals and high deductibles.

There are tradeoffs, and understanding andchoosing among plans isn't always easy. Remember, if you have questions call yourhealth plan and ask, or check with your hospital or doctor. If you still have questions, your state insurancedepartment or Consumer Assistance Program can help. With the Affordable Care Act, there's newsupport for consumers, so take advantage of it! Having health insurance protection is a goodthing, especially when you know how it works. We hope you're now better prepared for thenext time you have to pull that health insurance.

Card out of your wallet. Stay safe, America!
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