Frequently Asked Questions

 

Q. Is there a fee for me to talk to an agent or get a quote?
A. No. Talking to agents or getting a quote is free of charge.
Q. How do I get in touch with an agent in my area?
A. Two ways to get in touch with an agent is to answer the questionnaire or call the toll free number.
Q. How soon will an agent call me back if I cannot speak to one right away?
A.  12 to 24hrs, might be longer during the weekends and holidays.
Q. Do I have to go with the agent’s recommendation?
A. No. The Agent’s job is to give you options. You can either accept or reject the advice with no obligation.
Q. Is the Private Market Health choices website owned or controlled by the government?
A. No. This site is completely independent of the government. None of your information is shared with the government. 
Q. Can I still get an approved government plan after talking to an agent?
A. Talking to an agent does not stop you from purchasing a plan on the government exchange. This site  allows you to make better-informed decisions.
Q. Will I be penalized for buying a plan from an agent?
A. There is no penalty for buying a plan from an agent. However there could be a penalty for buying a plan that is not ACA approved. You and your agent can discuss which option works best for your situation.

 

Health Insurance Terms

Deductible

A specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims. Not all health insurance plans require a deductible. As a general rule (though there are many exceptions), HMO plans typically do not require a deductible while most  PPO plans do.

Drug Formulary

A list of prescription medications selected for coverage under a health insurance plan. Drugs may be included on a drug formulary based upon their efficacy, safety and cost-effectiveness. Some health insurance plans may require that patients obtain preauthorization before non-formulary drugs are covered. Other health insurance plans may require that a patient pay a greater share or all of the cost involved in obtaining a non-formulary prescription.

Coinsurance

The amount that you are obliged to pay for covered medical services after you have satisfied any co-payment or deductible required by your health insurance plan. Coinsurance is typically expressed as a percentage of the charge or allowable charge for a service rendered by a healthcare provider. For example, if your insurance company covers 80% of the allowable charge for a specific service, you may be required to cover the remaining 20% as coinsurance.

 

Co-payment

A specific charge that your health insurance plan may require that you pay for a specific medical service or supply, also referred to as a “co-pay.” For example, your health insurance plan may require a $20 co-payment for an office visit or brand-name prescription drug, after which the insurance company often pays the remainder of the charges.

 

Attending Physician Statement (APS)

A physician’s assessment of a patient’s state of health as outlined in office notes and test results compiled by the physician. An APS may be requested by an insurance company in lieu of a medical examination in order to determine the state of an applicant’s health for underwriting purposes.

 

COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985)

Federal legislation allowing an employee or an employee’s dependents to maintain group health insurance coverage through an employer’s health insurance plan, at the individual’s expense, for up to 18 months in certain circumstances. COBRA coverage may be extended beyond 18 months in certain circumstances. COBRA rules typically apply when an employee loses coverage through loss of employment (except in cases of gross misconduct) or due to a reduction in work hours.
COBRA benefits also extend to spouses or other dependents in case of divorce or the death of the employee. Children who are born to, adopted, or placed for adoption with the covered employee while he or she is on COBRA coverage are also entitled to coverage. All companies that have averaged at least 20 full-time employees over the past calendar year must comply with COBRA regulations.

 

Case Management

When a member requires a great deal of medical care, the health insurance company may assign the member to case management. A case manager will work with the patient’s healthcare providers to assist in the management of the patient’s long-term needs, appropriate recommendations for care, monitoring and follow-up. A case manager will also help ensure that the member’s health insurance benefits are being properly and fully utilized and that non-covered services are avoided when possible.

 

Dependent Coverage

Health insurance coverage extended to the spouse and unmarried children of the primary insured member. Certain age restrictions on the coverage of children may apply.

 

Durable Medical Equipment (DME)

Medical equipment used in the course of treatment or home care, including such items as crutches, knee braces, wheelchairs, hospital beds, prostheses, etc. Coverage levels for DME often differ from coverage levels for office visits and other medical services.

 

EPO(Exclusive Provider Organization)

An EPO is a Exclusive Provider Organization. As a member of an EPO, you can use the doctors and hospitals within the EPO network but cannot go outside of the network for care. There are no out-of-network benefits.

 

HMO

HMO means “Health Maintenance Organization.” HMO plans offer a wide range of healthcare services through a network of providers that contract exclusively with the HMO or who agree to provide services to members at a pre-negotiated rate. As a member of an HMO, you will need to choose a primary care physician (“PCP”) who will provide most of your health care and refer you to HMO specialists as needed.
Some HMO plans require that you fulfill a deductible before services are covered. Others only require you to make a co-payment when services are rendered. Healthcare services obtained outside of the HMO are typically not covered, though there may be exceptions in the case of an emergency.

 

Hospitalization

Typically, hospitalization services include services related to staying at a hospital for either scheduled procedures, accidents or medical emergencies. Hospitalization services typically do not include hospital stays for giving birth to a child.

 

Hospitalization Insurance

Insurance intended to provide coverage in case of hospitalization, including benefits for room and board and miscellaneous expenses, within certain limitations.

 

PPO

PPO means “Preferred Provider Organization.” Like the name implies, with a PPO plan you’ll need to get your medical care from doctors or hospitals on the insurance company’s list of preferred providers if you want your claims paid at the highest level.
You will probably not be required to coordinate your care through a single primary care physician, as you would with an HMO, but it’s up to you to make sure that the healthcare providers you visit participate in the PPO. Services rendered by out-of-network providers may not be covered or may be paid at a lower level. A broad variety of PPO plans are available, many with low monthly premiums.

 

Indemnity

Also called “fee-for-service” plans, Indemnity plans typically allow you to direct your own healthcare and visit whatever doctors or hospitals you like. The insurance company then pays a set portion of your total charges. You may be required to pay for some services up front and then apply to the insurance company for reimbursement. Indemnity plans typically do not require that you fulfill an annual deductible.
Because of the freedom they allow members, Indemnity plans are sometimes more expensive than other types of plans.
An Indemnity plan may be right for you if:
  1. You want the greatest level of freedom possible in choosing which doctors or hospitals to visit.
  2. You don not mind coordinating the billing and reimbursement of your claims yourself.

 

Major Medical Insurance

A type of medical insurance plan that provides benefits for a broad range of healthcare services, both inpatient and outpatient. Major medical insurance plans often carry a high deductible.

 

MSA (Medical Savings Account)

A tax advantaged personal savings account used in conjunction with a high-deductible health insurance plan. MSAs are currently being phased out and replaced with HSAs.

 

HSA (Health Savings Account)

A tax advantaged savings account to be used in conjunction with certain high-deductible (low premium) health insurance plans to pay for qualifying medical expenses. Contributions may be made to the account on a tax-free basis. Funds remain in the account from year to year and may be invested at the discretion of the individual owning the account. Interest or investment returns accrue tax free. Penalties may apply when funds are withdrawn to pay for anything other than qualifying medical expenses.

 

Medicaid

A state-funded healthcare program for low income and disabled persons.

 

Medicare

A national, federally-administered health insurance program authorized in 1965 to cover the cost of hospitalization, medical care, and some related health services for most people over age 65 and certain other eligible individuals.

 

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