Health Insurance Basics

There are several things you need to know before choosing a health insurance plan. Understanding your options, costs, and benefits can make a big difference in the quality of your care. This guide has the answers to help get you started.

Consumer Checklist: What to look for in Health Insurance

It can be difficult to find coverage that meets your health care needs and fits your budget. Here are some things to look for when shopping for insurance:

  1. Premium versus Protection – Health insurance that covers more tends to cost more. Do your best to weigh the cost of the policy with the protection it offers.
  2. Cost to You – Determine what you will have to pay for your policy, including costs for services.
  3. Benefits Offered – Check whether the plan covers the health care services and medications you require.
  4. Provider Network – Find out if your doctor accepts the type of insurance you are thinking about buying.
  5. Added Perks – Many insurance companies, including Community Health Plan of Washington, offer additional programs and services that are free to members. Look into what’s available to you beyond what’s covered in your policy.

Q: Under the Affordable Care Act, will I have to buy health insurance? What happens if I don’t?

A: Beginning in 2014, most people will have to purchase health insurance or pay a fine. For individuals, the penalty will start at $95 per year, or up to 1 percent of income, and rise to $695, or 2.5 percent of income, by 2016. For families, the penalty will be $2,085 or up to 2.5 percent of household income.

Q: How much will my policy cost me?

A: The answer is more complicated than you might think. The most prominent feature of any policy is the premium – the amount you pay (usually monthly) to a health insurance company for your policy. Every plan is different, so it is also important to understand how much you will have to pay when you get services. These costs can include:

  1. Deductible – how much you pay before your insurance coverage begins.
  2. Copay/Coinsurance – how much you pay for services after the deductible is met.
  3. Out-of-pocket Maximum – the most you will have to pay for your coverage during your policy period (usually one year) before your health insurance company begins to pay 100 percent of the allowed amount. Depending on your plan, this amount may or may not include premiums.

Q: What is the difference between a copay and coinsurance?

A: Copay is the dollar amount you may be required to pay as your share of the cost for a medical service or supply. A copay is usually a set amount, rather than a percentage. For example, you might pay $10 copay for a primary care office visit. Coinsurance is usually a percentage. It is the amount you may be required to pay as your share of the cost for services or prescription drugs. For example, you might pay 20 percent of the cost for a specialist visit.

Q: What are the different types of plans and network restrictions?

A: Traditional HMOs (Health Maintenance Organizations) and EPOs (Exclusive Provider Organizations) may restrict coverage to providers outside their networks. If you see a doctor or specialist that isn’t in the network, you will likely have to pay the full cost of services provided.
PPOs (Preferred Provider Organizations) or POSs (Point-of-Service Plans) give you a choice of getting care within or outside of the provider network, although the copay or coinsurance may vary if the care is out-of-network.
FFSs (Fee-for-Service Plans) usually don’t have networks.

Q: I’m considering joining Community Health Plan of Washington. As a member, will I be able to continue seeing my current primary care provider?

A: We contract with more than 2,500 primary health care providers and more than 14,300 medical specialists. To find out if your current provider is affiliated with Community Health Plan of Washington, call our customer service team at 1-800-440-1561 or search our online directory.

Q: What if I want a second opinion about my health care?

A: Tell your primary care provider (PCP) that you want a second opinion. Your PCP will refer you to a different provider within the Community Health Plan of Washington network with similar credentials, or you can choose one from our provider list.