The Health Insurance Marketplace (ObamaCare) helps uninsured people enroll in health coverage.

Private health insurance with savings based on your income. Plans cover essential health benefits, pre-existing conditions, and preventive care. Most people who apply through the Marketplace qualify for premium tax credits and savings on out-of-pocket costs based on household size and income.

Medicaid and the Children’s Health Insurance Program (CHIP). These programs provide free or low-cost coverage to millions of families with limited income. Many states are expanding Medicaid to cover more people. Find out what Medicaid expansion means for you.

Fees, exemptions, and qualifying coverage

Most people must have health coverage or pay a fee. If you don’t have coverage in 2015, you’ll pay a penalty of either 2% of your income, or $325 per adult ($162.50 per child) — whichever is higher.

An employer plan that covers “essential benefits” qualifies as coverage and no penalty would apply. The essential health benefits include at least the following items and services:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (such as surgery)
  • Pregnancy, maternity, and newborn care (care before and after your baby is born)
  • 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

Health Insurance Terms

Policy
A policy is a contract between an individual and an insurance provider. A policy can also exist between a provider and an individual’s sponsor, employer or community organization.

Deductible
Your deductible is a fixed dollar amount during the benefit period – usually a year – that you pay before your health provider starts to make payments for covered medical services. Plans may have both per individual and family deductibles. Some plans may have separate deductibles for specific services and deductibles may differ if services are received from a provider in or out of network.

Preferred Provider Organization (PPO) Plan
A plan where coverage is provided to participants through a network of selected health care providers (such as hospitals and physicians). Enrollees may go outside the network but would incur higher costs from these providers.

Health Maintenance Organization (HMO)
A health care system that assumes both the financial risks and responsibilities associated with providing comprehensive medical services (insurance and service risk) in a particular geographic area, usually in return for a fixed, prepaid fee. Financial risk may be shared with the providers participating in the HMO.

Primary Care Physician (PCP)
A physician who serves as a primary contact within a health plan. In a managed care plan, the primary care physician provides basic medical services, coordinates and often authorizes referrals to specialists and hospitals.

Explanation of Benefits
An explanation of benefits is a document that may be provided by an insurer to a patient outlining what is covered for a medical service and how payment amount and patient responsibility amount are determined.

Is Your Life In Transition?

Discover a short term health plan solution that fits your situation.

  • Recent Grad – Waiting for a new job’s health plan to kick in? Check out your options.
  • Current Student – Whether it’s a car accident or the flu, make sure you’re covered during college.
  • In-between Jobs Health Plans – Perhaps your employee benefits haven’t started. Or maybe your job is seasonal. You have choices.
  • Waiting for Medicare – Retiring early may open a gap in health coverage. Consider a temporary insurance plan.
  • Temporarily Unemployed – A short term health plan can serve as a COBRA alternative. Get details today.
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