Collection: Health Insurance FAQ's

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50 Most Common Questions and Answers About Health Insurance Plans

1. What is a Qualified Healthcare Plan (QHP)?
   • A QHP meets the requirements of the Affordable Care Act (ACA), covering ten essential health benefits and providing consumer protections.
2. What are non-qualified health insurance plans?
   • Non-qualified plans do not meet ACA standards and may have exclusions for pre-existing conditions, coverage limits, and lack certain benefits.
3. What are the ten essential health benefits covered by QHPs?
   • Emergency services, hospitalization, maternity and newborn care, mental health services, prescription drugs, rehabilitative services, laboratory services, preventive services, pediatric services, and ambulatory patient services.
4. How can I purchase a QHP?
   • Through the federal or state health insurance marketplace during open enrollment or a special enrollment period.
5. What is open enrollment?
   • A designated period each year when individuals can enroll in a health insurance plan through the marketplace.
6. What is a special enrollment period?
   • A time outside of open enrollment when you can sign up for health insurance due to life events like marriage, birth, or loss of other coverage.
7. Can I get financial assistance for a QHP?
   • Yes, premium tax credits and cost-sharing reductions are available for eligible individuals based on income and family size.
8. What is a premium tax credit?
   • A subsidy that lowers the monthly premium cost for health insurance.
9. What is cost-sharing reduction (CSR)?
   • A subsidy that lowers out-of-pocket costs like deductibles, copayments, and coinsurance for eligible individuals.
10. What income level qualifies for premium tax credits?
    • Individuals and families with incomes between 100% and 400% of the federal poverty level (FPL).
11. What income level qualifies for CSRs?
    • Individuals and families with incomes between 100% and 250% of the FPL.
12. What is a deductible?
    • The amount you pay out-of-pocket before your insurance starts to cover costs.
13. What is coinsurance?
    • The percentage of costs you pay after meeting your deductible, with the insurance company covering the rest.
14. What is a copayment (copay)?
    • A fixed amount you pay for a covered healthcare service, usually at the time of service.
15. What is the maximum out-of-pocket limit?
    • The maximum amount you pay during a policy period, after which the insurance company covers 100% of covered services.
16. What is a health maintenance organization (HMO)?
    • A type of plan that requires members to use in-network providers and get referrals for specialists.
17. What is a preferred provider organization (PPO)?
    • A plan that offers more flexibility by allowing members to see any doctor without referrals, though in-network providers cost less.
18. What is an exclusive provider organization (EPO)?
    • A plan that covers services only from in-network providers, except in emergencies.
19. What is a high-deductible health plan (HDHP)?
    • A plan with a higher deductible but lower premiums, often paired with a health savings account (HSA).
20. What is a health savings account (HSA)?
    • A tax-advantaged savings account for medical expenses, available to those enrolled in an HDHP.
21. Can I be denied coverage for a pre-existing condition?
    • Not with QHPs, which must cover pre-existing conditions. Non-qualified plans may have exclusions.
22. What are short-term health insurance plans?
    • Temporary plans that provide limited coverage for a short period, often not meeting ACA standards.
23. What are the penalties for not having health insurance?
    • The federal individual mandate penalty was eliminated in 2019, but some states have their own penalties.
24. How do I find out if my doctor is in-network?
    • Check the insurance company’s provider directory or contact the doctor’s office.
25. What are preventive services?
    • Services like immunizations and screenings that are covered without cost-sharing under QHPs.
26. How do prescription drug plans work?
    • They cover medications, either as part of a health insurance plan or as a separate plan. Formularies list covered drugs.
27. What is a formulary?
    • A list of medications covered by a prescription drug plan.
28. Do health insurance plans cover mental health services?
    • Yes, QHPs must cover mental health services as one of the essential health benefits.
29. What is catastrophic health insurance?
    • A plan with very high deductibles and low premiums, available to people under 30 or with a hardship exemption.
30. What is Medicaid?
    • A state and federal program providing health coverage to low-income individuals and families.
31. How do I qualify for Medicaid?
    • Eligibility is based on income, family size, and other factors. It varies by state.
32. What is Medicare?
    • A federal health insurance program for people 65 and older, and some younger individuals with disabilities.
33. What is the difference between Medicare and Medicaid?
    • Medicare is for seniors and certain younger people with disabilities. Medicaid is for low-income individuals and families.
34. Can I have both Medicare and Medicaid?
    • Yes, individuals who qualify for both can be "dual eligible" and receive benefits from both programs.
35. What is an employer-sponsored health insurance plan?
    • A health insurance plan provided by an employer, often subsidized to reduce costs for employees.
36. What are association health plans?
    • Plans that allow small businesses and individuals to band together to purchase health insurance.
37. What is the difference between in-network and out-of-network?
    • In-network providers have agreements with the insurance company to provide services at lower rates. Out-of-network providers do not, and costs are higher.
38. What is a referral?
    • A written order from a primary care doctor to see a specialist, often required in HMO plans.
39. Can I change my health insurance plan?
    • Yes, during the open enrollment period or if you qualify for a special enrollment period.
40. What is the Children's Health Insurance Program (CHIP)?
    • A program providing low-cost health coverage to children in families who earn too much for Medicaid but cannot afford private insurance.
41. What are wellness programs?
    • Programs offered by some health plans to promote healthy behaviors and reduce healthcare costs.
42. What is a managed care plan?
    • A health plan that contracts with medical providers and facilities to provide care for members at reduced costs.
43. What is a point-of-service (POS) plan?
    • A hybrid plan combining features of HMOs and PPOs, where you need a referral for specialists but have some out-of-network coverage.
44. What is a grandfathered health plan?
    • A plan that existed before the ACA was enacted and is exempt from some of its requirements.
45. What is a self-insured health plan?
    • A plan where the employer assumes the financial risk for providing healthcare benefits to its employees.
46. How do I appeal a denied claim?
    • Contact your insurance company to understand the reason for denial and follow their appeals process, which is outlined in your plan documents.
47. What is telehealth?
    • The delivery of healthcare services through electronic communication, often covered by health insurance plans.
48. What are out-of-pocket costs?
    • Expenses for medical care that aren’t reimbursed by insurance, including deductibles, coinsurance, and copayments.
49. What is the individual mandate?
    • A requirement under the ACA that most Americans have health insurance, though the federal penalty was eliminated in 2019.
50. What should I consider when choosing a health insurance plan?
    • Factors include coverage benefits, costs (premiums, deductibles, out-of-pocket limits), provider networks, prescription drug coverage, and whether the plan meets your healthcare needs.