Health Insurance Basics: Major Medical

Everyone needs health insurance. The basic purpose of health insurance is to provide protection for the family against catastrophic medical bills and situations. The goal of a family or individual when shopping for coverage should be to acquire insurance coverage that will pay the bulk of anticipated and unanticipated hospital, surgical and medical bills. QuotePick Health offers helping you find this coverage at the lowest out-of-pocket cost.

Watch our Youtube video on The Basics of Major Medical Coverage here.

Choosing a major medical plan requires researching the different companies and comparing costs for covered services.

Asking questions will help bring awareness to personal and familial needs for coverage.

What is an affordable monthly premium? How much is it to see a doctor or a specialist? Does anyone take prescriptions or need medical supplies? Does anybody play sports that might result in a visit to the emergency room?

There are different provider organizations but in major medical plans they all must provide the same 10 Essential Health Benefits.

1. Outpatient care

2. Emergency Care

3. Hospital Stays

4. Behavioral Health

5. Prescriptions

6. Rehabilitation

7. Lab Services

8. Preventive Care

9. Maternity and Newborn Care

10. Pediatric Care (includes dental and vision)

HMO (Health Maintenance Organization)	PPO (Preferred Provider Organization)	EPO (Exclusive Provider Organization)
Members of HMOs must go to a designated health center or centers for treatment and can usually only see physicians who are apart (in network) of the HMO	Members of PPOs can go in and out of network. However, patients of PPOs can expect to pay 60% of the bill when they go out of network	A cost efficient alternative to PPO plans. Freedom to self refer in network but there is a smaller group of doctors, facilities and hospitals participating than in a PPO plan
Pros: If your usual primary care doctor and specialists are in network with the HMO, you could save money by paying less in copays and monthly premiums	Cons: Usually there are higher monthly premiums and copays than in an in HMO plan even if staying in-network	Cons: Usually no out of network coverage unless its an emergency
Cons: Patients are limited to the provider choices available. If a patient goes out of network for care, they can expect to pay 100% of the bill
Cons: The primary care physician determines what sort of treatment the patient will receive and must be the one to refer patients to a specialist

Deductible

The amount a person owes for services that their health insurance plan covers before their plan

begins to pay is known as a deductible. The deductible is per plan year which is January through December.

Copay

A fixed amount paid for a covered health care service at the time of service. Generally, office visit copays and deductibles are collected during the patient check-in process.

Coinsurance

The share of the costs of covered health care services is calculated as a percentage of the

allowed amount for the service. The customer generally pays coinsurance after the deductible

has been met. The health insurance or plan pays the rest of the allowed amount. 

Maximum Out of Pocket

The most a customer will have to pay for covered services in a plan year. After this amount is

reached, the health plan will pay 100% for covered benefits. It includes the yearly deductible and

cost-sharing but doesn’t count premiums, balance billing amounts for non-network providers,

other out-of-network cost-sharing or spending for non-essential health benefits.

Explanation of Benefits

The explanation of benefits is a document showing the breakdown of services and their charges. It is sent from the health insurance carrier and should match the same amounts listed on the medical bill sent from the health care provider. The EOB can be used to confirm what the member will pay for covered services.

Summary of Benefits

The summary of benefits is a document provided by a health insurance carriers and it breaks down covered services and the members share of costs.

There are many different elements to consider when choosing a health insurance plan and with QuotePick Health it doesn't have to take days, months or years to understand. We can review everything in a matter of half an hour and help you secure peace of mind for yourself and your family. Please call, text or email us today!

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