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25 Questions to Ask When Buying Health Insurance

We have some frequently asked questions that will help you as you comparison shop health insurance rates online. Whether you're looking for a low-cost health insurance quote or just need clarity as to what health insurance can do, we're here to help.

1. How Does Health Insurance Work?

Understanding how health insurance works helps inform you of the many benefits of having your medical expenses covered. Basically, you pay a monthly premium, and the insurance company provides health coverage that helps pay the costs of medical-related expenses. Preventative care such as wellness check-ups, vaccinations, and certain preventive screenings will likely cost an additional copay (a small upfront amount paid for medical treatment), while other things like hospitalizations, surgeries, lab tests, anesthesia, and medical devices such as pacemakers will likely be paid for out-of-pocket until you meet your plan's deductible (what you pay before your insurance will cover your medical expenses).

2. How Much Is a Health Insurance Plan?

Cost is always an important factor when deciding your health insurance plan. The cost for coverage can range depending on where you live, your age, tobacco use, and the type of coverage you purchase. This includes the premium (what you pay to be covered), the deductible (what you pay before your insurance kicks in), copays (an upfront fee you pay for medical treatments), and possibly coinsurance (you usually pay 20% of a covered healthcare service and the insurance company pays 80%).

Medicare Advantage (Medicare Part C) bundles Medicare Parts A and B and usually Part D (prescription drug coverage).

3. Which Plan Is Best for Me?

The best health plan for an individual or family will vary significantly depending on a number of factors, including your financial situation, how often you visit the doctor, your medication requirements and hospital needs. Plans are broken up into four categories, Bronze, Silver, Gold, and Platinum, and they determine how you and your plan share costs. You will also need to be aware of the plan and network types, such as a Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Point of Service (POS), and Exclusive Provider Organization (EPO) as some will dictate what health care providers and health care facilities your insurance will cover.

4. What Does In-Network and Out-of-Network Mean?

In-network can be described as a business arrangement a health insurance company has with specific doctors or health care facilities wherein the doctor or facility agrees to charge a discounted rate to those people who are insured by that carrier. Out-of-network refers to doctors or facilities that do not have an agreement with an insurance company and ergo do not offer a discount for services. While an insurance company will still help pay for the costs associated with medical services, the discount that would normally be offered with an in-network healthcare service will not be applied meaning you will need to pay more for your care.

5. Is My Doctor Covered?

Not all health insurance plans cover the same physicians. The treatment you get from doctors who are not in your insurance's network will end up costing you more than if you go to someone who is in your insurance's network. Make sure you check with your provider to see who and what is covered.

6. What Benefits are Included in the Health Plan?

Health insurance benefits can vary from one plan to the next. Standard benefits that are mandatory for health care plans include doctors' services, inpatient and outpatient hospital care, mental health services, pregnancy and childbirth, and prescription drug coverage.

7. Are Prescription Drugs Covered?

Prescription drugs can be very expensive. Your health care plan should help cover the costs as long as the prescription in question is on your plan's approved list. If you're not sure if your prescription is covered, you can call your insurer directly, look at the coverage material that may have been sent to you or visit your insurer's website.

8. Are Routine Exams Covered?

It's important to know whether or not your health insurance will cover day-to-day health-related issues. Things like routine physical exams, mammograms and cholesterol screenings are typically covered by your insurance, possibly with a copay, a small cost you're charged during health-related visits.

9. What Happens in an Emergency?

Your provider cannot charge you more for emergency room care received from an out-of-network hospital. Emergency rooms must provide you with care regardless of your insurance.

10. What Is a Medicare Advantage Plan?

Medicare Advantage, also known as Medicare Part C, is an "all in one" healthcare plan offered by private insurance companies that bundles Medicare Part A (hospital insurance), Part B (medical insurance), and usually Part D (prescription drug coverage). Most plans also offer extra benefits like vision, hearing, and dental. In order to enroll in Medicare Advantage, you need to first have Medicare Part A and Medicare Part B.

The best health plan for you depends on your financial situation, how often you visit the doctor, your medication requirements and hospital needs.

11. Is a Health Insurance Premium Tax-Deductible?

Your health insurance premiums (including premiums for Medicare Part B, C, and D) can be tax-deductible if your expenses are over 7.5% of your adjusted gross income.  Other qualifying situations include your expenses being over 10% of your adjusted gross income, you have paid for your premiums with after-tax money, or you are self-employed with no medical coverage through work.

12. How do Health Insurance Deductibles Work?

A health insurance deductible refers to the amount you pay towards medical bills (not counting prescription drugs, usually) before your health insurer begins to pay your medical expenses. An HMO typically doesn't have a deductible although there is a type of coverage called a "deductible HMO" which does have a deductible. Things like wellness check-ups, vaccinations, or certain preventive screenings will either be covered or require a copay without the deductible being reached.

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13. Are There Penalties for Having No Health Insurance?

There is currently no federal mandate to have health insurance which means there is also no penalty fee. However, states are allowed to have their own laws regarding the purchase of health insurance. California, New Jersey, and Massachusetts, for example, have penalties for those without health insurance.

14. When Is Open Enrollment for Health Insurance?

The open enrollment period for health insurance begins on November 1. The ending date for 2023 open enrollment hasn't been released yet. The 2022 enrollment period ended on January 15, however, the ending date for open enrollment can vary from state to state. Always check your local deadlines!

15. Does Health Insurance Cover Therapy or Counseling?

Knowing if your health insurance covers psychological care, as well as physical care, is important. While most health insurance plans cover some mental health care costs, it does depend on each insurer and the plan your company or you choose. Make sure to tell your health insurance agent if you need a plan that has comprehensive mental health and behavioral health benefits coverage if this is something you'd need from your new health insurance policy.

16. How Long Can Children Stay on Their Parents' Health Plan?

You may be worried about whether your child will be removed from your insurance plan. According to current law, you can add or keep your children on your health insurance plan until they turn 26 years old. They can even be on the plan if they are not living with you and/or married.

17. What Is a Copay in Health Insurance?

A copay is a small portion of the cost you're responsible to pay for each medical treatment. Copays can range from $25 to $100 depending on the coverage you buy. The smaller the copay, the more expensive the premiums will be. The larger the copay, the less expensive the premiums will be.

The cost for coverage can range depending on where you live, your age, tobacco use, and the type of coverage you purchase.

18. What Is the Health Insurance Marketplace?

Every state has a health insurance marketplace that offers competitively priced health insurance plans. You can find your state at www.healthcare.gov. Compare and contrast plans while shopping for coverage so you get the best policy that fits your finances and needs.

19. Can You Cancel Health Insurance at Any Point?

You can cancel health insurance at any time but you can't buy a new plan at any time. For instance, let's say you have a very expensive private health insurance plan that you pay for 100% and you get a new job with a great plan that your employer will pay for partially. You may drop your individual health insurance plan and sign up for the group health plan at work, however, let's say you don't like your insurance and you'd like to switch insurers: You'd have to wait for open enrollment or wait until you have a qualifying event such as having a baby, moving, losing health coverage, getting married, adopting a child, your employment status changes and you work part-time, are laid off, or you quit, or if your household income is below a certain amount.

20. What Is Coinsurance in Health Insurance?

Co-insurance is the amount the policyholder is responsible to pay, which is a higher amount than a copay. For example, let's say Ann had to have surgery that cost $4,000. Let's say her copay is $50, and her co-insurance is 20% (a typical amount). Her share of the cost for the surgery would be 20% of $3,950. The insurance would pay the remaining 80%.

21. Does Health Insurance Cover Dental?

Health insurance will not cover bridges, cleanings, crowns, exams, fillings, and non-urgent X-rays. There are some dental procedures that medical insurance may pay for, including oral infections, cysts, oral inflammation, sleep apnea appliances, headache treatment, accidents affecting the teeth, mucositis and stomatitis from chemotherapy or other medical treatments, dental implants and bone grafts, wisdom teeth extraction, biopsies, botox injections for jaw pain and more.

22. Is Medicare the Same as Standard Health Insurance?

Besides private insurance, there is the option of Medicare for those who are 65 and older, for those with disabilities, or for those with end-stage renal disease. Medicare is government-run health care. Both Medicare and standard health insurance help cover the costs associated with medical treatment.

23. Can Health Insurance Save Me Money if I'm Not Healthy?

Having health insurance is still far cheaper than paying the full cost of your medical expenses. You never know when you may get injured too.

Not all health insurance plans cover the same physicians.

24. Do All Health Insurance Plans Have Alternative Therapy Options?

Alternative forms of therapy include chiropractic, massage, or acupuncture. Make sure you review what each available plan offers, especially if you're interested in alternative forms of care.

25. How Does the Company Handle Disputes Over Claims?

Make sure you understand how your insurance company handles disputes filed over claims. Typically, there will be two avenues to appeal a denied claim. You can either file an internal appeal wherein your insurance company does a thorough review of their decision and your situation, or file for an external review wherein a third party looks into the matter.

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