Hoosier Navigators have a number of responsibilities. Along with helping customers enroll in the Marketplace and choose a Qualified Health Plan, we are also tasked with teaching customers about the basics of health insurance. Many of our clients have never had health insurance before or they may have had a plan that they did not fully understand. Navigators are here to help customers comprehend the more finite details of health insurance such as co-pays, deductibles, premiums, and many other aspects. Having this knowledge allows customers to better utilize their coverage and take full advantage of it. Here are some general health insurance terms you will want to know:
- Premium: Payment to an insurance company or health care plan for health or prescription drug coverage.
- Deductible: The amount you own for health care services your health insurance plan covers before your health insurance plan begins to pay.
- Co-payment: A fixed amount (for example, $15) you pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.
- HMO (Health Maintenance Organization): In most HMO plans, you can only go to doctors, other health care providers, or hospitals on the plan’s list except in an emergency. You may also need to get a referral from your primary care doctor.
- PPO (Preferred Provider Organization): In a PPO plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You pay more if you use doctors, hospitals, and providers outside of the network.
- POS (Point of Service): A POS is a managed health care plan that is a hybrid of HMO and PPO plans. Like an HMO, participants designate an in-network physician to be their primary care provider. But like a PPO, patients may go outside of the provider network for health care services. When patients venture out of the network, they’ll have to pay most of the cost, unless the primary care provider has made a referral to the out-of-network provider.
- Primary Care Physician: The doctor you see on a regular basis for check-ups, exams, when you’re sick, or when you have a health care concern that is not an emergency.
- Preventative Care: Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Here are some terms and language that is specific to the Affordable Care Act:
- Advance Premium Tax Credit: A tax credit to help you afford health coverage purchased through the Marketplace. Advance payments of the tax credit can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount.
- Cost Sharing Reduction: A discount that lowers the amount you have to pay out-of-pocket for deductibles, coinsurance, and co-payments. You can get this reduction if you get health insurance through the Marketplace, your income is below a certain level, and you choose a health plan from the Silver plan category.
- Metal Tiers: The four types of coverage that is available on the Marketplace which are divided into Platinum, Gold, Silver, and Bronze. If a consumer is eligible for a Marketplace plan, the different tiers will be available for purchase and he can choose the plan that best suits his coverage needs and budget.
- Medical Loss Ratio: A financial measurement used in the Affordable Care Act to encourage health plans to provide value to enrollees. If an insurance plan does not use 80% of monthly premiums toward health care costs, the insurance company must pay back customers annually. The remaining 20 cents of each premium dollar can pay overhead expenses, such as marketing, profits, salaries, administrative costs, and agent commissions.
- Lifetime Limits on Care: Before ACA legislation was passed, many health insurance plans had a “lifetime limit on care” meaning that once customers reached that limit they could be excluded from further coverage. ACA legislation now makes this practice illegal.
If you come across health insurance terms that you do not understand, I strongly recommend that you contact a local Navigator to assist you. Even if you are not interested in a plan from The Marketplace, your local Navigator can answer general questions regarding health insurance literacy, ACA legislation, and requirements for coverage.
Meridian Health Services has licensed Navigators who are happy to help. You can call Meridian to set up an appointment with a Navigator by calling (765) 288-1928 or email us at firstname.lastname@example.org. We currently have Navigators in the following Indiana counties: Delaware, Wayne, Jay, Henry, Randolph, Rush, and Fayette. If you do not live in these counties but still need assistance, you can visit http://www.healthcare.gov to find a list of Navigators near you. You can also call the Health Insurance Marketplace Call Center at 1-800-318-2596, 24 hours a day, 7 days a week. TTY users should call 1-855-889-4325. You can find a list of Navigators in your area at https://localhelp.healthcare.gov.