Frequently Asked Questions

HealthMarkets searches plans nationwide to find the right fit for you. But with all those options, you’re bound to have questions.

Most popular topics

The Affordable Care Act (ACA), also known as Obamacare, is a health reform law enacted in 2010 with the goal of making affordable health insurance available to more people. In order to qualify for subsidies, you must meet the following criteria:

You are currently living in the United States
You are a US citizen or legal resident
You are not currently incarcerated
Your household income falls within a certain range

There are many different factors that define which health insurance coverage option is best. These factors include:

Job status
Income
Age

For example, an individual who has lost their health insurance coverage due to the loss of a job may qualify for Consolidated Omnibus Budget Reconciliation Act (COBRA).

An individual over the age of 65 or under the age of 65 with certain disabilities may qualify for Medicare.

Click here to find out what health coverage options could be available to you..

Learn about different types of plans

Medicare is a government program that provides free or very discounted health care to eligible people who enroll. You may be eligible for Medicare if you:

Are 65 years old or older (even if you are still working), or
Are any age and disabled, or
Have End-stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)

There are different parts of Medicare to help cover specific services:

Medicare Part A covers stays in the hospital, nursing facility, hospice care, and some home health care
Medicare Part B covers certain doctors’ services, outpatient care, medical supplies and preventive services
Medicare Part D covers the cost of prescription drugs (including shots and vaccines)

Most people do not pay a monthly premium for Part A coverage. Everyone will pay a monthly premium for Part B coverage.

You can either opt in to Part D coverage (called an original Medicare plan), or choose an all-in-one alternative that bundles Part A, Part B, Part D coverage (also called Medicare Advantage Plan).

Click here to see if Medicare may be right for you.

Dual eligibility is when an individual qualifies for both Medicare and Medicaid. If an individual meets the federal requirements for Medicare and the state requirements for Medicaid, then they are dual eligible.

For example, if you are over the age of 65 and your income is below the federal poverty line, then you may qualify as dual eligible. Click here to check your eligibility.

These metal tiers were set up through the Affordable Care Act in support of individual packages. Each tier covers a certain percentage of health care costs.

SIMPLIFYING HEALTH PLAN TERMS

A premium is how much you pay a health insurance company each month to access a health insurance plan.

A copay is a set rate you pay for prescriptions, doctor visits, and other types of care. Coinsurance is the percentage of costs you pay after you’ve met your deductible.

A deductible is the amount you pay for eligible health care services (e.g. doctor and hospital visits, medical procedures) each year before your health insurance pays its portion of the cost.

Bronze plan

This is usually best for people who are healthy but want coverage for emergency medical situations and do not require frequent visits to a doctor. Wellness visits are covered.

Lowest monthly premiums
Highest out-of-pocket costs (copay/coinsurance)
High deductibles

Silver Plan

This is often a good plan for an individual or family in need of routine care.

Moderate monthly premiums
Moderate out-of-pocket costs (copay/coinsurance)
Moderate deductibles

Gold Plan

This may be a great plan for someone who needs routine care on a regular basis and prefers to pay a little more each month as opposed to paying more for each visit.

High monthly premiums
Low out-of-pocket costs (copay/coinsurance)
Low deductibles

Platinum Plan

This may be a great plan for someone who regularly needs care and can pay higher monthly premiums while having most if not all costs covered.

Highest monthly premiums
Lowest out-of-pocket costs (copay/coinsurance)
Very low deductibles

SIMPLIFYING HEALTH PLAN TERMS

A deductible is the amount you pay for eligible health care services (e.g. doctor and hospital visits, medical procedures) each year before your health insurance pays its portion of the cost.

A high-deductible health plan is a private plan with a higher deductible. The monthly premium for these plans is often lower, but an individual pays more for healthcare costs themselves before the insurance company starts to pay.

Health insurance basics

SIMPLIFYING HEALTH PLAN TERMS

Wellness is the state of being in good health.

Some health plans exist to cover you in the case of an emergency, while others offer a whole world of wellness programs and benefits with the purpose of keeping you healthier longer. See below for two examples.

Pharmacy and prescription drug benefits

If you’ve ever needed prescription drugs, you know they can play an important role in keeping you healthy. Maybe you take regular medications — or maybe you’ve only needed medication for specific treatments. No matter what, it’s helpful to know how your benefits work.

Vision and dental benefits

Dental and vision benefits are often not included within many health plan options. If they are important to you, consider purchasing a separate, standalone dental or vision plan.

A pre-existing condition is a medical illness or injury that you had before you started to receive coverage from a new health insurance plan. No ACA-qualified insurance plan can reject you, charge you more, or refuse to pay for essential health benefits for any pre-existing condition you had before your coverage started.

Once you’re enrolled, the plan can’t deny you coverage or raise your rates based only on your health.

Health care costs

Some people get their health insurance through their employer, or group insurance. Some decide to purchase it for themselves, or an individual plan (even if family members are included). Others get it through government programs. The cost of health insurance depends on several factors:

Age
Income
Where you live
Number of family members needing health insurance coverage
Health care use
Whether your employer or the government covers part of the cost

A copayment, or copay, is the fixed amount you pay each time you see a network provider. Some plans require you to pay copays instead of meeting a deductible. Other plans may require you to pay both a copay and meet a deductible.

For example, if your plan has a $20 copayment and your doctor's visit is $150, if you:

Haven’t met your deductible: you’ll pay $150 at the time of your visit.
Have met your deductible: you’ll pay your $20 copayment. The insurance company will pay the rest.

The amount you pay for copay or coinsurance is decided by your health insurer and pricing varies. Your copay or coinsurance amount will be listed in your insurance documents or on your ID card.

SIMPLIFYING HEALTH PLAN TERMS

In-network care is when a health provider has a signed agreement with your health insurance company to provide care for plan members at a certain rate.

Out-of-pocket maximum is the most you have to pay for covered health services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan will pay 100% of the cost of covered benefits.

The out-of-pocket limit doesn't include:

Your monthly premiums
Anything you spend for services your plan doesn't cover
Out-of-network care and services
Costs above the allowed amount for a service that a provider may charge

Coinsurance is a way for health insurers to split costs with you. It is based on a percentage of covered health care services after you have met your deductible. For example, if you have 30% coinsurance and your doctor’s visit is $150:

If you haven’t met your deductible: you’ll pay $150 for the visit
If you have met your deductible: you’ll pay 30% of $150 ($45). The insurance company will pay the rest.

The amount you pay for copay or coinsurance is decided by your health insurer and pricing varies. Your copay or coinsurance amount will be listed in your insurance documents or on your ID card.

When deciding between different health insurance options, the goal is to maximize your dollars for the best quality care, and there are different cost factors to consider with this in mind. Here are a couple of examples.

Premium

The amount you pay, usually monthly, for your plan. Premiums are a fixed amount you pay, whether you use health care services or not.

Copayment (or Copay)

To see other cost examples besides premium and copayment, look through the rest of the FAQ’s.

We are here every step of the way to help you through any questions you may have. HealthMarkets is your resource to help simplify health insurance with clear answers and help you compare your options to find the plan that works for you. No matter who you are, we're here to help you find coverage options you may qualify for!

Ready to see your options? Click here.

Frequently Asked Questions

HealthMarkets searches plans nationwide to find the right fit for you. But with all those options, you’re bound to have questions.

Most popular topics

What are the requirements to be eligible for ACA subsidies?

What types of health insurance coverage options are available to me?

Is it important to have health insurance?

Learn about different types of plans

What is Medicare?

What is Medicaid?

What is dual eligibility?

What are the differences between bronze, silver, gold, and platinum health plans?

Bronze plan

Silver Plan

Gold Plan

Platinum Plan

What is a PPO Plan?

What is a POS Plan?

What is a EPO Plan?

What is a high-deductible health plan?

Health insurance basics

Is there a penalty for not having health insurance?

How long can a child stay on a parent’s health insurance plan?

How does my current situation affect my health insurance coverage options?

Do I need specific kinds of health insurance benefits?

What is a pre-existing condition? And do pre-existing conditions affect health insurance coverage?

Health care costs

How much does health Insurance cost?

What is a deductible?

What is a copayment?

What is out-of-pocket maximum?

What is coinsurance?

What is a premium?

What costs should I consider when choosing a health insurance option?

What is the best way to purchase coverage?

Get to Know Us