What is health insurance?
It’s a way to pay for health and medical care. Health insurance is also known as a health plan or “benefit program.” You pay a monthly fee or a “premium” to keep your health insurance.
Why have health insurance?
Health insurance protects you from unexpected and high costs due to a hospital stay or treatment for an injury or when you are sick. Your health insurance plan could help pay for some or even all of these costs.
What type of services does health insurance pay for?
Insurance pays for covered services. Your benefit plan documents will show the services your insurance carrier will pay for or “cover.” There are also “non-covered services” or services that your insurance carrier will not pay.
How does health insurance work?
The insurance carrier pays a portion of your medical costs with the premium money from all the people they insure. In the same way, your premium helps pay medical costs for others when they need it. You lose your insurance if you do not pay your premium.
What other costs, besides premium, could I have with my health plan?
Additional costs outside of the premium are called out-of-pocket costs. Below are some kinds of out-of-pocket.
You may have to pay a “deductible.” A deductible is the amount you pay each year toward health care costs before the insurance company pays. When you meet your deductible, your insurance begins to cover a portion of costs. Example: Your deductible is $500. Your insurance pays for your claims after you have paid the first $500 in medical costs. Some services will be paid even though you have not met your deductible. Preventive and other wellness screenings may be covered before you meet your deductible.
A “co-payment” or “co-pay” is another out-of-pocket cost you may need to pay. The co-pay is the fee that you pay at the doctor or facility office.
You may also have “coinsurance” or “cost-sharing” costs. Coinsurance is the cost you pay for a medical service when you get it. Coinsurance applies after you reach your deductible. For example, if your health plan has a 20% coinsurance, you pay $20 of a $100 doctor bill. The insurer pays the remaining $80.
What is medical loss ratio (MLR)?
The medical loss ratio (MLR) requires that insurance companies spend a certain percentage of premium dollars on medical claims and activities to improve care quality. Rebates are due to members if an insurer fails to meet minimum loss ratios of 80 percent in the individual and small group markets. For each calendar year, Capital Blue Cross and its affiliates will calculate and issue payments, if required, to eligible policyholders by September 30th of the following calendar year.
Capital Blue Cross
Medical loss ratio summary
January 1 – December 31, 2019
|Individual||Small group||Large group|
|CBC||Not Credible||Not Credible||99.7%|
|CAIC||Not Credible||Not Credible||106.9%|
What are the types of plans?
Health maintenance organization (HMO)
Choose a Primary Care Physician (PCP) for routine care, like check-ups or sick appointments. Your PCP will refer you to other healthcare providers when you need specialty care. If you need care from a specialist in the network or a diagnostic service such as a lab test or X-ray, your PCP will provide you with a referral. Services provided by out-of-network providers are not covered unless urgent or an emergency.
Preferred provider organization (PPO)
With a PPO you have the flexibility to choose which doctors you want to see — you do not need a referral. If you receive your care from an in-network provider, your out of pocket cost will be lower than if you go to an out-of-network provider. If you get health services from a provider that is out-of-network, you will pay a higher amount.
Available only to individuals who reside in Lancaster county.
PPO Choice is a health plan accepted by most doctors and hospitals with extra savings when you get care from certain healthcare providers. For greater savings and lower out-of-pocket costs, visit PPO Choice 1 providers. PPO Choice 2 providers offer you more access to care, giving you flexibility and convenience to choose doctors and hospitals without referrals. Integrated care through PPO Choice can lead to better communication between doctors, which means fewer duplicate tests and quicker test results. This plan provides peace of mind when you travel.
Valley Advantage EPO
Available only to individuals who reside in Lehigh and Northampton counties.
This health plan provides high-quality benefits and services with renowned doctors and hospitals of St. Luke’s University Health Network and other independent practices throughout the Lehigh Valley. With a network of 500 independent community physicians, in addition to 800 St. Luke’s providers, we deliver the care you need, when you need it.
Exchange and metal levels
Why are exchange health plans named by color?
Each health plan group is named for a color of metal, called “metal level.” The colors also signify the level of coverage they give: Bronze, Silver, Gold and Platinum. Metal levels show the amount of cost you pay under your health plan and the amount of cost the insurer pays. Your cost is in addition to your premium.
|Actuarial value of 60%. This means it's designed to pay 60% of essential health benefits across all the people covered by this type of plan. Members as a whole pay 40%. Lowest monthly premium of all metal levels; least generous cost coverage||Actuarial value of 70%. This means that it's designed to pay 70% of essential health benefits across all the people covered by this type of plan. Members as a whole pay 30%.||Actuarial value of 80%. This means that it's designed to pay 80% of essential health benefits across all the people covered by this type of plan. Members as a whole pay 20%.||Actuarial value of 90%. This means that it's designed to pay 90% of essential health benefits across all the people covered by this type of plan. Members as a whole pay 10%. Highest monthly premium of all metal levels; most generous cost coverage.||Requires you to pay all medical costs up to a specific limit before insurance company begins payment of your covered services. The specified limit is usually several thousand dollars. Low monthly premium.|
How to understand exchange plans:
Compare metal levels.
Think about the premium price that will work best for your budget. Your premium will be lower if you choose to pay more when you go for doctor visits or medications. The premium will be higher if you choose to pay less at the time of a doctor visit or for medicine.
Health insurance exchange subsidy
Do I qualify for lower costs?
The government has different guidelines for different levels of income. If you are eligible, you must buy a Pennie qualified health plan to get the subsidy. To determine and confirm a subsidy, also called APTC, please visit Pennie's financial assistance page.
What if I’m not eligible?
Your income determines eligibility. If you aren’t eligible, you’ll need to pay the whole cost of the premium.
Will I get a big or small premium tax credit?
A subsidy might pay all, most or only part of the premium cost for a health plan.