Health Insurance 101

Understanding health insurance is not an  easy task. Many Americans are confused by the terms, how their benefits work, which doctors and hospitals they can see, what type of coverage they have, what’s included in their coverage, etc. Last year, a report by the American Institute of Certified Public Accountants revealed that more than half of Americans surveyed could not explain common health insurance terms including premium, co-pay, deductible, etc.

Typically, Americans choose health plans based on preferred doctors they want to see or based on which plans provide the most coverage for the health benefits they are seeking. If an individual does not have a specific health need, they usually just pick the most affordable plan with what they think is “good coverage.” Today, network provider coverage is much more limited in order to keep costs down.

To help you better understand your benefits, we’re breaking down the five main insurance terms you need to know in today’s lesson of “Health Insurance 101″:

  • Deductible: The amount of expenses you pay out of pocket before an insurance provider will pay for any of the expenses.
  • Co-pay: A fixed cost for a service. This is typically the amount you pay when you visit your regular physician (not a specialist) for help.
  • Premium: The amount you pay each month, quarter, or year to the insurer to obtain health insurance.
  • Preventive Care: All health plans have certain services they cover known as “preventive care” which include some immunizations, cholesterol screening, blood pressure screening, many cancer screenings, and more. These services do not require you to pay any out of pocket costs or require that you meet your deductible before seeking attention.
  • HMO/PPO: An HMO plan limits the number of in-network providers you can seek but usually for a more affordable cost. To seek an out of network provider, one must have a note from their physician first. A PPO plan has more flexible benefits and usually more providers. However, the cost of a PPO plan is generally higher than that of an HMO plan.


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Mental Health Illness Declared Essential Benefit for Medicaid Patients

Last week was Mental Health Awareness Week. However, mental health awareness should not be limited to strictly one week of dialogue and information. Mental illness can be a life threatening disease if untreated and the signs and symptoms are often complicated. While more people have started to acknowledge the severity of mental illnesses especially as this nation mourns the loss of comedian Robin Williams, accessing healthcare for the treatment of a mental illness is still challenging.

Why don’t people with a mental illness seek treatment?

  • Individuals fear that their friends, family, and employers will find out they are seeking help
  • The cost of seeking help can be expensive
  • Many people who seek help fear that they won’t be able to obtain life insurance later on

Currently, there is no legislation in place to help mental health patients receive proper treatment. is a site that was built by the government to help patients get treatment, learn information about mental health conditions and improve mental healthcare in America. However, their lack of decisions regarding ongoing treatment and programs to help these individuals is something Americans need to become more aware of. Americans have the power to vote on these issues and help get mental health treatment on ballots during election years.

This year is even more important to discuss how we plan to continue helping patients with mental illnesses because last year the Affordable Care Act declared mental health treatment an “essential benefit” for Americans participating in Medicaid. This declaration lead to an influx of patients seeking help there aren’t enough doctors eligible to treat them. Therefore, they want help but can’t get the help they need. Mental illness can be deadly so it’s important to get educated, become aware of the signs and symptoms, and learn how you can make a difference in helping mental health patients get help.

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What You Need to Know for Open Enrollment

The open enrollment period is November 15th through February 15th. The open enrollment period is a specified time frame where health insurance companies are required to accept applicants. This is the only period where you can enroll in a new plan or get covered through the rest of the year (unless their is a qualifying event).

Here are 5 things you need to know for open enrollment in 2015 plans:

  • Check to make sure the cost of your coverage did not increase dramatically. Health insurance premiums will increase in 2015 so it’s important to check your renewal rates and make sure they are within your current budget.
  • Compare different plans. If you don’t like your current plan, this is the time to change it. If you have other medical needs that need to be accounted for or plan on having a baby and would like additional coverage, this is the time to weigh your options. Open enrollment enables you to look at the cost and value of different plans to ensure you are getting the best benefit for the cost. Whether you want to switch plans or not, we recommend looking into alternative options.
  • Penalties will increase for being uninsured. The penalty for individuals is will now be 2% of your income above the filing threshold. Uninsured adults will have to pay $325 and uninsured kids will be fined a penalty of $162.50 making the family maximum $975.
  • Subsidies are available. If enrolling under the exchange, look into filing for a government subsidy for assistance with paying for coverage.
  • If you are covered under a 2014 plan under the federal exchange, you’ll either be automatically renewed or notified that you cannot be renewed. Be sure to look out for notices regarding your coverage. They will be sent out stating that you can be automatically enrolled with the same tax credit and subsidy in 2015 as 2014 or it will tell you that your plan cannot be renewed, in which case you’ll have to select an alternative plan.


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Covered California One Year Review

On October 1st 2013, Covered California launched. It has been one year and while it initially kicked off to a shaky start with numerous website crashes, officials are looking back into the success of the program and prepping for the open enrollment launch next month.

The goal of Covered California in 2014 is to renew participants that enrolled last year as well as encourage eligible participants to sign up. Covered California Director Peter Lee states that they are coordinating numerous outreach plans in their market strategy to make 2014 a success.

Was 2013 Open Enrollment Successful?

  • 3.4 million individuals enrolled in Covered California health plans
  • California’s uninsured rate was cut in half
  • 42% of the pre-determined eligible market enrolled
  • Website  experiences numerous technical issues and outages during times of high interest
  • Call centers had long wait lines
  • Finding doctors who would accept coverage for many individuals became an issue
  • Complaints and lawsuits filed against Anthem Blue Cross

If you are judging the success of Covered California by how effectively it fulfilled its goal of enrolling applicants, then it could be deemed more successful than most states. However, the true judgement of success should be whether people renew in Covered California. After the technical glitches, high demand for doctors, and website outages, it will be interesting to see how many people continue their plans in 2015.

What Should You Expect In November:

  • Premium rates increased by nearly 4.2%
  • Ads encouraging 2015 enrollments
  • Covered California representatives claim to be working on an improved experience for the consumer.

What do you hope to see from Covered California in 2015?


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Small Business Plans for Covered California Announced

SHOP is the Small Business Health Options Program operating under Covered California that will begin in 2015 for businesses with 50 or fewer employees. Small businesses will have the option to offer insurance plans through SHOP rather than through carriers not on the Covered California plan. According to Covered California Executive Director Peter Lee, this gives employers more flexibility in the types of plans and quality of coverage they are offering to employees.

How will the SHOP work?
Under SHOP, employers will be able to offer employees coverage from two pre-selected metal tiers similar to the individual tiered plan under Covered California. Unlike the individual market where consumers can select among one of four options, employers who choose to participate in SHOP must offer plans that are adjoining such as Bronze and Silver, Silver and Gold, or Gold and Platinum. An employer cannot select a Bronze plan and a Platinum plan to offer employees. While this is meant to make employee benefits more competitive and valued, in reality this limits the flexibility of the employer to appease individual employee needs.

5 Things You Need To Know About SHOP:

  • Employers have the option to offer additional benefits like dental plans for adults in 2015 (Dental benefits will be employee paid only)
  • There are 6 health plans and 10 dental plans
  • Businesses with 50 or fewer employees are not required to get benefits through SHOP and there is no penalty for choosing not to enroll in coverage with SHOP
  • Businesses with 25 or fewer employees who choose to enroll in SHOP will be eligible for a tax credit
  • Open enrollment for SHOP is available year round (1,714 businesses are currently enrolled)
For a list of the health plan carriers and dental providers covered through SHOP in 2015, click here.
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