Health Insurance Terms and Meaning

In network
You can start your health insurance comparison by asking yourself if you have a favorite hospital or physician. You'll want to make sure they are included in the network of any plan you consider purchasing. If they are not included you should look for a different plan.

Doctor visit copay
When you get health insurance, a number that will often come into play is your plan's copay. The copay is the amount you will pay each time you visit the doctor.

Prescription benefit and copay
Some plans do not include prescription drug benefits-you'll want to keep this in mind while you make your health insurance comparison. If coverage is included, the copay is the amount you will pay per prescription. The copay often differs depending on whether the drug is generic, preferred, or brand name. Before buying health insurance, you should calculate your current and estimated future cost of medications and determine your best value.

Annual deductible
This is the annual amount of medical expenses that you are responsible for before your insurance begins paying.

Another factor you will want to consider in your health insurance comparison is the plan's coinsurance--the amount your carrier expects you to pay toward your medical expenses-typically this is 20-30% for in-network providers. The coinsurance amount is typically 20% higher for out-of-network providers.

Out of pocket  annual maximum
Buying health insurance will always involve some amount of out of pocket maximum. The out of pocket maximum is the most you will be expected to incur each calendar year. It is the sum of your deductible and maximum coinsurance amount along with all prescriptions.

Lifetime maximum coverage
Since the Affordable Care Act has gone into effect, there are no maximums that the insurance company will pay on your behalf.

Perhaps the most basic number to consider before buying health insurance, your premium is the amount you must pay each month for your policy. Premium is impacted by all of the attributes above. For instance, if you get a health insurance plan with a higher deductible policy, your premium will be lower, but you will have to pay more money out of pocket before your insurance kicks in.

HSA Qualified Plans
HSA's are high deductible health plans which enable you to put money aside pre-tax to pay for certain medical expenses. Most people like to weigh the costs and benefits of HSA's in their health insurance comparison.

HMO’s, POS’, and PPO’s

Health Maintenance Organization (HMO): These Plans provide insurance if you receive services from an in-network provider. The only out-of-network services available are those on an emergency basis. Many HMOs require enrollees to see a primary care physician (PCP) chosen by the member who will refer them to a specialist if deemed necessary for high-cost services like MRIs or surgeries. HMOs can cost less due to the network only coverage but it is important to check your doctors to make sure they are participating.

Preferred Provider Organization (PPO): These plans include a managed care arrangement consisting of a group of hospitals, physicians, and other providers who have contracts with an insurer to provide health care services to enrollees at a predetermined rate.  PPO health insurance plans also allow members to see physicians and hospitals out of the insurance company's network; however, these visits will require higher out-of-pocket costs for the member.  Generally PPO’s allow for a greater coverage area and are many times the choice for a national network.  Most health insurance plans on the individual marketplace today are PPOs. The benefits of going with a preferred provider, or in-network, are typically much greater than if you used a non-preferred physician, hospital, or other provider. Deductibles for out-of-network are typically much higher, co-insurance can be 20% higher, and some plans actually have limits on how much out-of-network coverage is available.

Point-of-Service (POS) Plan: POS plans are like a hybrid of HMO and PPO plans. It is a form of managed care that allows an individual to choose between services from a provider in the plan network or outside of the network, with varying levels of reimbursement. Generally, you pay less for in-network care. For out-of-network care, you usually pay a deductible and coinsurance. A POS plan allows for out of network flexibility but they are generally local area networks to be considered in network coverage.

Where Do I Get These Health Plans?

Individual Policies: Individual health insurance is coverage that a person buys independently. It can be sold to a single individual, to a parent and dependent children, or to a family.  Today individual insurance maybe purchased ON Exchange or OFF exchange.  On Exchange policies are purchased through your states exchange with assistance from a navigator or broker, OFF exchange policies can be purchased through Barnum Benefit Advisors.

Group Policies: You may be able to get group health coverage through your job or the job of a family member. Most employers allow you to change your health plan once a year during an open enrollment period. However, once you choose a plan, you must keep it for a year. You should always discuss your choices and limits with your employee benefits office.

State Exchange: As part of the Affordable Care Act each state has made it possible to purchase health insurance through what is called a state Exchange.  Here in Connecticut this exchange is called Access Health CT.  Plans are available from the insurance companies and if you are eligible based on household income this is the only way you can access the tax credits and subsidies the affordable Care Act has made available.

Medicaid: Medicaid is a joint state and federal program for public assistance to eligible people, regardless of age, whose income and resources are insufficient to pay for healthcare. In some cases, states require people covered under Medicaid to join managed care plans. Insurance plans and state regulations differ, so check with your state Medicaid office to learn more.

Question & Answer Individual Coverage

What does it mean to purchase ON exchange policies?
To purchase an ON exchange policy you must register an account and apply through the state exchange website or in person at a certified brokers office or navigator site.  The state exchange in Connecticut is called Access Health CT and the website to apply is  The state exchange is the only way to receive the advance tax credits and/or plan subsidies the ACA has made possible for those eligible.  It is important to consider that these plans offer reduced networks of doctors and prescription lists as compared to the OFF exchange plans. Below are guide lines to determine eligibility in this program, below these limits you may be eligible for financial assistance through a subsidy.

1 person household-Modified Adjusted Gross Income:  $47,520

2 person household-MAGI:  64,080

3 person household- MAGI:  80,640

4 person household- MAGI:  97,200

What does it mean to purchase a policy OFF exchange?
Off exchange plans are purchased through a broker directly or through the insurance carrier.  No tax credits or subsidies are available regardless of eligibility if plans are purchased in this manner.  OFF exchange plans offer more extensive physician networks along with larger prescription lists.

Is it cheaper to buy a plan ON exchange?
Not necessarily, plan pricing ON and OFF is very similar as are the plans available the major difference is that through the exchange is the only way to access the ACA  credits if you or your family are eligible.

What CT Insurance Carriers offer coverage?
Anthem and Connecticare offer plans both ON and OFF exchange.

Can I apply at any time?
Open enrollment is from November 15th through February 15th for effective dates starting January 1.  If you do not have coverage now or miss this open enrollment period you may still be eligible to apply through a special enrollment if you have a qualifying event. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby).  Proof of qualifying event must be included with your application. Outside of the Open Enrollment Period or a qualifying event, you can only enroll during the Open Enrollment Period.

Do I have to have coverage?
Yes, the ACA has made it a law that we all must have health insurance coverage. If you choose not to have coverage you will be assessed a tax penalty when you file your taxes at the end of the year.  This penalty will increase as years pass.  Most importantly, not being covered exposes you to the high cost of medical care and prevention that these plans are in place to control.

Do I need to go through medical review to be approved?
No, new laws are in place to protect against medical underwriting or pre -existing condition exclusions.  All plans will be approved without the possibility of rate changes based on medical history.

How long does it take to get coverage?
If you application is received in good order it can be processed by the carrier in 7-10 business days.  Most carriers require the application to be submitted by the 15th of the month for your coverage to be effective the 1st of the following month.  Cards usually go out 5-7 days after policy approval and installation.