Individual and Family

Protection for you and your loved ones start with health insurance. Please call us at 415-250-8279 so we can better determine your needs.

What Kinds of Health Plans Can I Choose From?

There are plenty of family and individual health plans to choose from. Here are the most common types:

PPOs (Preferred Provider Organization). The PPO is the most flexible and comprehensive network. Similar to an EPO, you may choose your own primary care physician and physician. However, different than an EPO, you are able to see Out-of-Network doctors and facilities at a higher precentage of the costs than the in-network doctors and facilities. As an example, if you need to go to an out-of-network “Stanford” hospital, your precentage of the cost will be more than seeing an in-network “UC Berkeley” hospital. You will be covered for a US emergency, regardless of which Hospital, Clinic, Urgent care facility you receive care. The PPO is great for flexible, comprehensive, and affordable health care.

EPO’s (Exclusive Provider Organization). EPOs are similar to HMO’s except they do NOT have the “gatekeeper” approach to health care. You may choose your own primary care physician and specialists in the network. EPO’s create networks of doctors, hospitals, clinics, specialists, and other care providers. You will be covered for a US emergency, regardless of which Hospital, Clinic, Urgent care facility you receive care. For non-emergencies or to see a provider out of this exclusive network, it will be your responsibility to pay for all out of network costs.

HMOs (Health Maintenance Organization). HMOs have the “gatekeeper” approach to health care. You are assigned to a primary care physician, who will determine what specialists you are able to see. (However, you may ask to have a change in your assigned primary care physician). HMOs create networks of doctors, hospitals, clinics, specialists, and other care providers. You will be covered for a US emergency, regardless of which Hospital, Clinic, Urgent care facility you go to. For non-emergencies or to see a provider out of this maintenance network, it will be your responsibility to pay for all out of network costs.

HSAs (Health Savings Account) Plans. HSA’s are an optional component of a HMO, EPO or PPO plan. There are 2 parts to HSA coverage: a high-deductible plan and a Health Savings Account. The high-deductible plan provides catastrophic coverage and features low monthly premiums. The HSA is a tax-free savings account where you save money to pay for routine medical expenses. An insurance carrier that offers PPO, EPO and/or HMO plans, can elect to attach an approved HSA plan.

FFS (Fee For Service) Plans. The FFS plan is the traditional form of health insurance. It works very simply — you get the care you need, then you’re reimbursed for a percentage of the cost.

What are Premiums, Deductibles, Copayments, Coinsurance and Out of Pocket Maximums?

Understanding The Costs of Personal Health Insurance Plans

Your premiums. Your premiums are payments you make to keep your plan in effect. Usually, premiums are paid each month. Premiums are set by your insurance company based on factors such as age, household size, where you live, and where you work. For those that qualify for tax credits and/or subsidies, it will include your income for plans through CoveredCA, California’s public exchange.

Your deductible. The deductible is the dollar amount you’ll be responsible for before your plan begins coverage. Health plans outside the public exchange will let you choose your own deductible, so how do you choose the amount that’s best? It might seem like a lower deductible would be better. But a low deductible means you’ll have to pay higher monthly premiums. It works the other way too — the higher your deductible, the lower your monthly premiums. You’ll have to decide if you want lower monthly premiums or lower medical bills for your health care.

Copayments and coinsurance. If you pay something like $15 at the doctor’s office for a check-up. That’s called your copayment. You pay a certain dollar amount of the bill and your plan covers the rest. Coinsurance is similar to a copayment, except it’s expressed as a percentage rather than a dollar amount. A coinsurance rate of 80/20 means you’ll be responsible for 20% of the cost for certain services on the a medical bill.

Your out of pocket maximum. This is the “calendar year” maximum amount you will pay for in-network covered services. Some plans include the copays as part of the maximum and some do not. PPO plans offer out of network providers at an additional Out of Network maximum.

How are Plans Offered?

You and your family can choose plans either with private marketplace (off-exchange) or in the public exchange (federal or state run exchanges) Some insurance companies will provide both off and on exchange plans and some will only provide private off-exchange plans.

1. Public Exchange (For those who demonstrate they will qualify for a tax credit and/or subsidy by reporting their income and residency information). Public exchange plans are only available through the public exchanges. Individuals and families are able to consult with their trusted licensed health insurance advisor to discuss the plans most suitable to their needs. and the

2. Private Marketplace (Where income will not be a factor in getting the plan). Private plans are offered off-exchange. Plans offered on the private marketplace will be plans that “Mirror” or look exactly public exchange plans but with a different plan name and plans that are similar to those plans which may include additional benefits, deductibles, etc. There are insurance providers that will only offer plans “off exchange” or in the private marketplace.

What are the 10 Essential Health Benefits offered on all ACA Compliant Plans?

All newly purchased plans after January 1, 2014, regardless of whether they are purchased in the private or public marketplace, will include the 10 Essential Health Benefits. These Benefits are:

  • Ambulatory patient care
  • Children services including pediatric dental and vision care
  • Emergency services
  • Hospitalization
  • Lab services
  • Maternity and newborn care
  • Mental health and substance abuse disorder treatment
  • Prescription drugs
  • Preventative and wellness services and chronic disease support
  • Rehabilitation and habilitation services and devices
What plans are available through CoveredCA (for those who qualify for a subsidy)?

Platinum 90. Covers 90% of your costs annually for in-network health insurance covered benefits. These plans may include tax credits, lowering your monthly premium. These plans have the most expensive monthly premium payments.

Gold 80. Covers 80% of your costs annually for in-network health insurance covered benefits These plans may include tax credits, lowering your monthly premium. These plans generally have the 2nd highest monthly premiums.

Silver 70. Covers 70% of your costs annually for in-network health insurance covered benefits. These plans may include tax credits, lowering your monthly premium. These plans generally have the 2nd lowest monthly premiums.

Enhanced Silver 73, 87, 94. Covers 73%, 87%, 94% of your annual in-network health insurance costs. These plans offer subsidies and tax credits. Generally the 2nd lowest monthly premiums.
Bronze 60. Covers 60% of your costs annually for in-network health insurance covered benefits

These plans may include tax credits. These plans generally have the least expensive monthly premium payments. Bronze 60 Plans also have an HSA option Plan.

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