Based on the history of legislation and laws, here are the 5 main categories of Health Insurance being utilized today:
There are a number of factors you should consider within these 5 main categories of health insurance. It shouldn't be, but it is indeed somewhat complicated. Understanding and finding the best coverage for you can be a daunting task. InsuranceSaver is here to help and give you recommendations along the way.
Within Medicare, there are various plans available. Some of which are government funded, some that are partially funded or subsidized, and others that are not funded, but available from private insurance companies. How much of the plan that is government funded and subsidized depends on your eligibility as well as the types and levels of products and services offered in any given plan.
You can start the Medicare enrollment process three months prior to turning 65. You can be eligible for Medicare at an earlier age if you have received social disability insurance for more than 24 months, if you have been diagnosed with ESRD (End Stage Renal Disease) or if you have been diagnosed with Amyotrophic Lateral Sclerosis (also known as ALS or Lou Gehrig's disease).
To describe Medicare in a nutshell, we'll separate out 3 different product and services groupings:
Original Medicare covers inpatient hospital care (Part A) and outpatient Doctor care (Part B) plus some home health care and preventive services. Part A is typically subsidized by the government while Part B is only partially subsidized and requires you to pay a monthly premium. Original Medicare Part A and Part B will not cover products and services such as:
Original Medicare covers up to 80% of doctor and hospital care. Medicare Supplement Insurance plans are products sold by private insurance companies to cover the 20% or more gap. Medigap generally covers copayments, deductibles and Foreign Travel Medical emergencies that Original Medicare does not cover. You pay a monthly rate to avoid certain copayments, coinsurance and deductibles. Medigap coverage benefits are standardized into different "Parts" of coverage, see chart below.
|Benefits/Services||Medigap Coverage Parts|
|Medicare Part A Coinsurance & Hospital Costs|
|Medicare Part B Preventive Care Coinsurance|
|Medicare Part B Coinsurance & Copays||50%||75%|
|Blood (first 3 pints)||50%||75%|
|Part A Hospice Care Coinsurance & Copays||50%||75%|
|Skilled Nursing Facility Care Coinsurance||50%||75%|
|Medicare Part A Deductible||50%||75%||50%|
|Medicare Part B Deductible|
|Medicare Part B Excess Charges|
|Foreign Travel Emergency||80%||80%||80%||80%||80%|
Medicare Advantage are privately managed plans that may cover additional services beyond the standard Medicare part A and B coverage. Typically, Medicare Advantage plans may cover extras such as prescription drugs, dental, hearing, vision, wellness programs and home health care. You can consider Medicare Advantage plans bundles of health insurance products and services, where some parts are government subsidized and others are covered by you through monthly premiums, deductibles and copays. Medicare Advantage typically uses a defined network of Doctors and service facilities Health Maintenance Organizations and Preferred Provider Organizations (HMO's and PPO's) where if you need to see a doctor outside of the given network, you may end up paying more for the services.
Medicare Advantage and Medicare Supplement Insurance plans typically require an annual commitment. There is a set time-range every year, when existing Medicare beneficiaries can switch or modify their Medicare Advantage health insurance plan, this is commonly referred to as the Annual Election Period. The Annual Election Period (AEP) runs from October 15th through December 7th every year. When you sign up for a plan during AEP, coverage will typically start January 1st of the next year.
The short answer is yes—plans change and your coverage needs are likely to change over time. We recommend that you review your coverage needs during AEP, connect with a licensed insurance agent and see if there are opportunities for you to save on your overall health costs.
Things that could change include:
You can start the Medicare enrollment process three months prior to turning 65. You can be eligible for Medicare at an earlier age if you have received social disability insurance for more than 24 months, if you have been diagnosed with ESRD (End Stage Renal Disease) or if you have been diagnosed with Amyotrophic Lateral Sclerosis (also known as ALS or Lou Gehrig's disease). Medicare Advantage and Medicare Supplement Insurance plans typically require an annual commitment. There is a set time-range every year, when existing Medicare beneficiaries can switch or modify their Medicare Advantage health insurance plan, this is commonly referred to as the Annual Election Period. The Annual Election Period (AEP) runs from October 15th through December 7th every year. When you sign up for a plan during AEP, coverage will typically start January 1st of the next year.
Individual & Family Health Insurance Plans — this is your choice if you do not have employer-provided insurance, if you are planning on full or semi-retirement before you become eligible for Medicare (age 65 for most people) or if you otherwise need to buy your own health insurance.
Health Insurance Plans are issued by private health insurance companies or carriers. They are often categorized into Comprehensive and Short-Term Plans.
The major distinctions between the two:
Some people refer to short-term plans as "just-in-case" plans because they typically provide coverage, up to a pre-set limits, for accidents or unforeseen illnesses for people that do not have a comprehensive health insurance plan. Short-term plans are not usually meant as a long-term replacement for comprehensive plans because short-term plans generally do not cover items that many people need in the long-term, such as preventive care or coverage for pre-existing conditions.
States that currently significantly limit or do not allow short-term plans include California, Colorado, Connecticut, Hawaii, Massachusetts, New Jersey, New York, Rhode Island, Vermont and Washington (as of April 2019.) As an additional incentive for people to maintain comprehensive health insurance, some states may assess a tax penalty for people who do not maintain qualifying health insurance. Short-term plans do not count as qualifying health insurance. This tax penalty may affect residents of Massachusetts, New Jersey, and the District of Columbia in 2019, and Vermont in 2020. Additional states are considering adopting this tax penalty because the federal government stopped enforcing this penalty in 2019.
Everyone in the United States should carry health insurance given the cost of healthcare in this country. There are a number of health insurance plans and options out there ranging from limited, short-term coverage, to more comprehensive coverage across a broad range of products and services. The best plan and value for you will depend on your needs and budget.
The short answer is yes—plans change and your coverage needs are likely to change over time. We recommend that you review your coverage needs during OEP, connect with a licensed insurance agent and see if there are opportunities for you to save on your overall health costs. Things that could change include:
In addition, if you have a short-term plan, OEP is the best time to consider upgrading to a comprehensive health insurance plan. Outside of OEP, only people with qualifying life events can buy comprehensive health insurance plans.
Comprehensive health insurance plans are typically available for purchase during the Open Enrollment Period (OEP). There is a set time every year when anyone can apply for a comprehensive health insurance plan. At other times of the year, you need to have a qualifying life event (such as a change in family status or loss of other coverage) to buy these plans. The Open Enrollment Period generally runs from November 1st through December 15th each year, but the exact dates may vary by state or year. When you sign up for a plan during OEP, coverage will typically start January 1st of the next calendar year.
You may be eligible for Special Enrollment Period (SEP), meaning you can buy a comprehensive health insurance plan outside OEP. Generally, you have 60 days to apply if you have a qualifying life event such as:
When you consider various insurance products and what kind of services they offer, it can quickly get confusing and complicated. To help you along the way, we have created a list of products and services with a general description of what they mean to you.
A typical insurance plan, whether it's Private Health Insurance, Company Sponsored, Medicare, Medicare Advantage may only cover some of the products and services below. There will also usually be other limitations such as a percentage copay or a maximum amount of hospital nights, or days of covered prescriptions, just to name a few examples.
An important step in evaluating which health insurance plan is right for you, is to understand the details and any limitations of the coverage products and services you need. The list below is only a guideline. The definition and scope of coverage may also vary by plan type and the insurance company that offer the plans. To help you through all the details, you may want to consider discussing your needs with a licensed insurance agent from one of our trusted partners.
|Office Visit Primary Doctor||Typically, an outpatient visit to the office of a primary care physician (or PCP) for illness or injury.|
|Office Visit Specialist Doctor||Typically, an outpatient visit to a medical specialist's office for illness or injury.|
|Emergency Room||Typically, emergency room services include all services provided when a patient visits an emergency room for an emergency condition. An emergency condition is any medical condition that would lead most lay people to believe that failing to obtain immediate medical care could result in placing the patient's health in serious jeopardy.|
|Ambulance Services||Transport by ambulance to or from a hospital from your home or a medical facility to receive medical care. Medicare covers the following types of ambulance services depending on the seriousness of your medical condition or whether other methods of transportation could endanger your health: emergency ground (vehicle), emergency air (airplane or helicopter) and non-emergency ground.|
|Outpatient Lab/Radiology/X-Ray||Labs and X-rays help your doctor diagnose or rule out a medical condition. Lab services typically include blood tests and urinalysis. Radiological services typically include plain-film X-ray, outpatient ultrasound, GI tests, MRIs and CT scans. Depending on the situation, prostate cancer screenings, mammograms and pap smears may also be covered under the lab/Radiology/X-ray benefit, or they may be covered by the OB-GYN or preventive care benefit. Typically, dental X-rays are not included in the lab/X-ray benefit.|
|Outpatient Surgery||Often defined as any surgical procedure that does not require an overnight stay in a hospital.|
|Urgently Needed Services||Care that you get outside of your Medicare health plan's service area for a sudden illness or injury that needs attention but isn't life threatening. If it's not safe to wait until you get home to get care from a plan doctor, the health plan must pay for the care.|
|Outpatient Rehabilitation Services||Outpatient services help you regain abilities, such as speech or walking, that have been impaired by an illness or injury. These services are provided by nurses, as well as by physical, occupational and speech therapists. Examples include working with a physical therapist to help you walk or working with an occupational therapist to help you get dressed.|
|Skilled Nursing Facility||A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services.|
|Home Health Care||Health care services and supplies a doctor decides you may receive in your home under a plan of care established by your doctor. Medicare only covers home health care on a limited basis as ordered by your doctor.|
|Preventive Care||Typically, periodic health exams that occur on a regular basis for preventive purposes, including routine physicals or annual check-ups.|
|Doctor Hospital Choice||Whether you can choose your hospital or doctor depends on the type of plan. With Original Medicare, you can choose any doctor or hospital that accepts Medicare. Medicare Advantage plans may require you to visit doctors and hospitals in their network. Medicare Supplement Insurance plans do not have networks; you can see any doctor or hospital that accepts Medicare. Please note: Medicare SELECT requires you to use hospitals and, in some cases, doctors within its network to be eligible for full insurance benefits (except in an emergency.)|
|Dental Services||Routine dental care, such as routine check-ups, cleaning, fillings or dentures.|
|Hearing Services||Routine hearing benefits, such as hearing aids and examinations.|
|Vision Services||Routine eye services, including eyeglasses or contact lenses and eye exams.|
|Chiropractic Services||Chiropractic services provided by a licensed chiropractor.|
|Outpatient Mental Health Coverage||Typically for services provided by a mental health professional in an outpatient program.|
|Fitness Benefits||Membership and access to Fitness Programs, such as a Gym membership or Fitness Training class.|
|Out of Network||An in-network provider is one contracted with the health insurance company to provide services to plan members for specific pre-negotiated rates. An out-of-network provider is one not contracted with the health insurance plan. Typically, if you visit a physician or other provider within the network, the amount you will be responsible for paying will be less than if you go to an out-of-network provider.|
|International Travel Emergency||Health coverage for when you are traveling outside of the United States.|
|Tier 1: Preferred Generic Rx||Typically includes most generic drugs that have been on the market for a time and are widely accepted. Generic drugs are chemically the same as brand-name drugs with regard to their active ingredients, dosage, safety, strength, how they are taken and what they are used to treat. A generic drug is called by its "chemical" name instead of a "brand" name and is typically sold at a lower price. Talk to your doctor about your medication options. In most cases, your doctor can prescribe a generic drug instead of the "brand-name," saving you money when you fill the prescription.|
|Tier 2: Generic Rx||Chemically equivalent versions of brand name drugs that can be approved by the FDA once the brand's patent or other periods of exclusivity in the market expire.|
|Tier 3: Preferred Brand Rx||Typically the brand-name drugs that have been in the market for a time and are widely accepted. May include medications manufactured by one manufacturer that are typically lower-cost among all brand-name drugs.|
|Tier 4: Non-Preferred Brand Rx||Includes higher cost, non-preferred generic and brand-name drugs.|
|Tier 5: Specialty Tier Rx||Includes other higher cost brand-name specialty drugs.|
|Standard Mail Order Cost-Sharing||Some plans will provide discounted rates (varies by Tier) on Rx if you order the drugs with the insurance carrier directly, for Mail Order shipment.|
Now that you have a better understanding of the types of products and services that may or may not be covered in a plan, it's time to take you through our IMX™ recommendation engine and have you talk to a professional.