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Health Care Basics

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Health Care Basics

Health insurance helps pay costs when you need care

No one plans to get sick or hurt, but your health can change in the blink of an eye. Most people need medical care at some point. Health insurance helps pay for these costs and protects you from very high expenses.

WHAT IS HEALTH INSURANCE

Health insurance is a contract between you and an insurance company. You buy a plan, and the company agrees to pay part of your medical costs when you get sick or hurt.
All plans offered in the Marketplace cover these 10 essential health benefits:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care (but adult dental and vision care aren’t essential health benefits)

Health insurance is a contract between you and an insurance company. When you buy a plan, the company agrees to pay part of your medical costs when you get sick or hurt.

FREE PREVENTIVE CARE

Most health plans must cover a set of preventive services, like shots and screenings tests, at no cost to you. This is true even if you haven’t met your yearly deductible. Preventive services prevent or detect illness at an early stage when treatment is likely to work best. These services are free only when you get them from a doctor or other provider in your plan’s network.

Here are some common services for all adults:

  • Blood pressure screenings
  • Cholesterol screenings: certain ages + those at high risk
  • Depression screenings
  • Immunizations
  • Obesity screenings and counseling

Visit Healthcare.gov/coverage/preventive-care-benefits/ for a full list of preventive services for all adults, women, and children.

HELPS YOU PAY FOR CARE

Did you know the average cost of a three-day hospital stay is $30,000? Or that fixing a broken leg can cost up to $7,500? Having health insurance can help protect you from high, unexpected costs like these.
Your insurance policy or summary of benefits and coverage will show you what types of care, treatments, and services your plan covers, including how much the insurance company will pay for different treatments in different situations.

  • Different health insurance policies can offer different benefits.
  • You may have to pay a deductible each plan year before your insurance company starts to pay for your care.
  • You may have to pay coinsurance or a copayment when you get medical care.
  • Health insurance plans contract with networks of hospitals, doctors, pharmacies, and health care providers.

WHAT YOU PAY 

You’ll usually pay a premium every month for health coverage, and you may also have to meet a deductible each year. A deductible is the amount you owe for covered health care services before your health insurance or plan begins to pay. The deductible may not apply to all services.

How much you pay for your premium and deductible is based on the type of coverage you have. The policy with the cheapest premium may not cover many services and treatments.
Just as important as the premium cost and deductible is how much you have to pay when you get services.

Examples include:

  • What you pay out-of-pocket for services after you pay the deductible (coinsurance or copayments)
  • How much in total you’ll have to pay if you get sick (the out-of-pocket maximum)

GET READY TO ENROLL

FIVE THINGS YOU CAN DO TO GET READY TO ENROLL

  1. Meet your local navigator or visit HealthCare.gov. Learn more about the Health Insurance Marketplace, and other programs like Medicaid, and the Children’s Health Insurance Program (CHIP).
  2. Ask your employer if it offers health insurance. If your employer doesn’t offer health insurance, you can get coverage through the Marketplace or other sources.
  3. Make a list of questions before it’s time to choose your health plan. For example, “Can I stay with my current doctor?” or “Will this plan cover my health costs when I travel?”
  4. Gather basic information about your household income. You’ll need income information from your W-2, pay stubs, or tax return.
  5. Set your budget. There are different types of health plans to meet a variety of needs and budgets. You’ll need to figure out how much you’re able to spend on premiums each month, and how much you want to pay out-of-pocket for prescriptions or medical services.

1. PUT YOUR HEALTH FIRST

  • Staying healthy is important for you and your family.
  • Maintain a healthy lifestyle at home, at work, and in the community.
    Get your recommended health screenings and manage chronic conditions.
  • Keep all of your health information in one place.

2. UNDERSTANDING YOUR HEALTH COVERAGE

  • Check with your insurance plan or state
  • Medicaid or CHIP program to see what services are covered.
  • Be familiar with your costs (premiums, copayments, deductibles, co-insurance).
  • Know the difference between in-network and out-of-network.

3. KNOW WHERE TO GO FOR CARE

  • Use the emergency department for a life threatening situation.
  • Primary care is preferred when it’s not an emergency.
  • Know the difference between primary care and emergency care.

2. UNDERSTANDING YOUR HEALTH COVERAGE

  • Check with your insurance plan or state
  • Medicaid or CHIP program to see what services are covered.
  • Be familiar with your costs (premiums, copayments, deductibles, co-insurance).
  • Know the difference between in-network and out-of-network.

3. KNOW WHERE TO GO FOR CARE

  • Use the emergency department for a life threatening situation.
  • Primary care is preferred when it’s not an emergency.
  • Know the difference between primary care and emergency care.

4. FIND A PROVIDER

  • Ask people you trust and/or do research on the internet.
  • Check your plan’s list of providers.
  • If you’re assigned a provider, contact your plan if you want to change
  • If you’re enrolled in Medicaid or CHIP, contact your state Medicaid or CHIP program for help.

5. MAKE AN APPOINTMENT

  • Mention if you’re a new patient or have been there before.
  • Give the name of your insurance plan and ask if they take your insurance.
  • Tell them the name of the provider you want to see and why you want an appointment.
  • Ask for days or times that work for you.

4. FIND A PROVIDER

  • Ask people you trust and/or do research on the internet.
  • Check your plan’s list of providers.
  • If you’re assigned a provider, contact your plan if you want to change
  • If you’re enrolled in Medicaid or CHIP, contact your state Medicaid or CHIP program for help.

5. MAKE AN APPOINTMENT

  • Mention if you’re a new patient or have been there before.
  • Give the name of your insurance plan and ask if they take your insurance.
  • Tell them the name of the provider you want to see and why you want an appointment.
  • Ask for days or times that work for you.

6. BE PREPARED FOR YOUR VISIT

  • Have your insurance card with you.
  • Know your family health history and make a list of any medicines you take.
  • Bring a list of questions and things to discuss, and take notes during your visit.
  • Bring someone with you to help if you need it.

7. DECIDE IF THE PROVIDER IS RIGHT FOR YOU

  • Did you feel comfortable with the provider you saw?
  • Were you able to communicate with and understand your provider?
  • Did you feel like you and your provider could make good decisions together?
  • Remember: it is okay to change to a different provider!

8. NEXT STEPS AFTER YOUR APPOINTMENT

  • Follow your provider’s instructions.
  • Fill any prescriptions you were given, and take them as directed.
  • Schedule a follow-up visit if you need one.
    Review your explanation of benefits and pay your medical bills.
  • Contact your provider, health plan, or the state Medicaid or CHIP agency with any questions.

Source: Your Roadmap to Health. Centers for Medicaid & Medicare Services. Sept. 2016.

This page is supported by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $1,000,000 with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the U.S Government.  

     

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