Health Insurance and Medicare can be confusing. We’ll make it simple with this “Health Insurance 101” primer. Simply scroll down and educate yourself on health insurance and Medicare basics.
We all know health insurance is a must, and that there are seemingly an endless amount of options. Even if you are covered by work or Medicare eligible, it’s still not straightforward.
Add in Obamacare, Trumpcare, and the never-ending political debate, and you have a situation where even a Ph.D. can be confused! But relax, we’ve got you covered with this quick primer on the most common situations and terms you’ll hear regarding health insurance.
In plain terms, health insurance provides coverage for doctor visits, hospital visits and stays, and prescription drugs. Since these costs can be astronomical, everyone needs health insurance.
There are different health insurance plans for covering different amounts of people. These break down as follows:
Most Health Insurance comes in “metal” tiers – Platinum, Gold, Silver, and Bronze. These affect the deductibles and premiums. Platinum has the highest premiums and lowest deductibles, where Bronze is the opposite. Obviously, a job that offers its employees Platinum-level health insurance with all add-ons is generally seen as very desirable.
Premium – How much the health insurance costs. If covered through work, an employer will cover most (or in some cases all) of the premium.
Deductible – The amount a consumer must pay “out of pocket” before insurance coverage kicks in. The higher the deductible, the lower the premium. For example, if a policy has a $3,000 deductible, the consumer must pay $3,000 in associated doctor and hospital visits (this can vary) before insurance kicks in.
Co-Pay– A fixed amount a consumer must pay for a healthcare service (such as a doctor visit), even if it’s covered. Generally $10-$40.
Out of Pocket Maximum– The most a consumer will pay for healthcare. All payments (premiums, co-pays, and deductibles) count towards this. This was brought on by Obamacare to protect consumers facing extended medical costs (such as cancer treatments).
HMO– Short for Health Maintenance Organization, this is seen as a way to control costs by banding together doctors and health care services, and having insurance cover them.
In Network / Out of Network– Used with an HMO. If you go “in-network” (doctors or services who are part of the HMO), the insurance covers you much better than if you go “out of network”. This may limit consumer choice of doctors, which is the main criticism of HMO’s.
Obamacare – The pet name for the “Affordable Care Act”, which is a set of laws governing health insurance. The main parts of it are the mandate, which states everyone must buy health insurance or pay a tax penalty, the removal of preexisting conditions as a reason for denying healthcare, the introduction of out-of-pocket maximums, and allowing children to remain covered by their parent’s plans until the age of 26.
Trumpcare– Technically undefined as of this writing, it’s simply a catchphrase for President Donald Trump’s attempt to roll back Obamacare.
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Medicare is the name for government-provided health insurance, and it’s available to people aged 65+, and other citizens with certain disabilities.
Medicare Part A covers hospital services and nursing facility stays. Medicare Part B covers doctor visits, lab tests, outpatient hospital treatment, and similar. Together, these are commonly referred to as “Original Medicare”.
There is no fee for Medicare Part A, and Medicare Part B generally covers 80% of services (and also carries a deductible and monthly fee.)
Medicare Part C (aka “Medicare Advantage”) is essentially Medicare Parts A and B that are provided by Medicare-Approved private insurance companies. They generally have in-network doctors and services, and have associated costs that vary with the plans. They also may offer things not covered by Medicare Parts A and B, like vision and dental and prescription drugs. In general terms, they are also seen as having better service than Government-run Medicare, which is part of their selling point.
Medicare Part D is also known as the Medicare Prescription Drug Plan. It’s optional, and the prescriptions covered will vary by plan.
Also known as Medicare Gap or “Medigap”, Medicare Part D is optional health insurance that covers costs that are not covered by Medicare.
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