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Health Insurance
Frequently Asked Questions about Health Insurance
With so many health insurance options to consider, the more you know, the better decisions you’ll make. We’ve made it easy by providing you the answers to the most frequently asked questions.
Health Insurance Basics
Q. What is a copayment?
A copayment is a set amount that you pay for a specific service, such as $20 for a physician office visit or $500 for an inpatient hospital admission (no limit to how many days). You are usually responsible for payment at the time of service.
Q. What is a deductible?
A deductible is the amount you pay each calendar year before your health insurance benefits are paid for covered medical expenses.
Q. What is coinsurance?
Coinsurance is the percentage of covered expense you are responsible for after you meet your deductible. For example, your plan has a 20% coinsurance of $5000 (which equals $1000). That means you’ll pay 20% and the company will pay 80% of the first $5000 (which equals $4000) of covered expenses. After that, the company pays 100% of covered charges for the remainder of the year, up to the policy maximum.
Q. What is individual out-of pocket expense?
It’s the maximum amount in covered charges you’ll pay—per person, per calendar year. The amount is determined by adding your deductible and coinsurance together.
Q. What is family out-of-pocket expense?
Like individual out-of-pocket it’s the combined total of your deductible and coinsurance, but for your whole family.
Plan Differences—Things to Consider
Q. Do all health plans offer the same benefits?
Not all health plans offer the same benefits. When you are shopping for health insurance, look for plans that offer a range of options. Within your budget look for plans that cover the essentials that meet your needs.
Q. What is an HMO?
HMO (Health Maintenance Organizations) are both insurers and health care providers. The following are HMO’s in San Juan County:
Lovelace Health Plan
Presbyterian Health Plan
Blue Cross Blue Shield of New Mexico
They accept responsibility for a specific set of health care benefits through a network of physicians and hospitals (San Juan Independent Physicians Association). Members of HMO’s pay co-pays or benefits (specific costs for specific benefits, Example: $500 total charge for an in-hospital admission, annual deductibles do not apply.)
Q. What is a PPO?
PPO’s (Preferred Physician Organizations) are groups of physicians (and hospitals who’ve agreed to provide their services at a discounted rate (to the insurer). Members receive a discounted benefit if they stay in a specific network. Co-pays, annual deductibles and co-insurance apply to all PPO’s.
The following offer PPO’s in San Juan County:
Lovelace Health Plan
Presbyterian Health Plan
Blue Cross Blue Shield of New Mexico
Q. What is the difference between a network and a non-network (or out-of network) medical provider?
A network provider is a doctor of hospital who’s made arrangement to provide services a discounted rate. Simply put, you’ll typically pay less for services from a network provider than a non-network provider.
Q. Do plans cover dental or vision care?
Generally, health insurance plans do not cover dental and vision care (unless it’s caused by an accident). Dental and vision plans are available as separate coverage.
Cost Options
Q. How can I help reduce the costs of my insurance coverage?
The easiest way to reduce your costs is to buy a plan with a higher copayment or deductible.
Q. What is the difference in plans with higher or lower premiums?
It’s really about choice and degree of care. Typically, you’d choose a higher premium plan if you want your health insurance to pay mainly for routine needs with a minimal cost to the insured. For example, $20 for a physician office visit or $500 for a hospital admission (total charge). You’d choose a lower premium plan if you want your health insurance to protect you against a serious illness or injury. You’ll pay for the costs associated with everyday heath care needs (catastrophic coverage).
Choosing your Insurance Company
Q. What should I consider when looking at a health plan and the company that offers it?
Working with major insurance companies, we can assemble individual and group benefit plans to meet the specific needs of your business.