Welcome to Your Guide to Health Insurance
Learn how Health Insurance works, the costs and get help choosing the right plan for your needs and budget.
Learn how Health Insurance works, the costs and get help choosing the right plan for your needs and budget.
What do you get with health insurance? Security. Stability. An open door to a doctor when you’re sick, and regular checkups that help keep you and your family healthy. But what does health insurance pay for – what does it actually "cover?" And what types of things will you pay for?
Exactly what your specific health insurance offers will depend on the package you select – what health insurance companies call a "plan." Beginning in 2014, all health insurance plans sold directly to individuals will include essential health benefits. (Plans purchased through your employer or individual health insurance companies may offer these benefits, too.) But note that you may be responsible for paying some out-of-pocket costs for these items and services.
Many health insurance plans also offer additional items, like visits to the dentist or eye doctor, and healthy lifestyle coaching designed to help you lose weight or quit smoking. Other plans may make discounts available on health products or gym memberships. Naturally, a plan with "all the extras" may cost more, in the form of a higher premium or more out-of-pocket costs.
While the Annual Open Enrollment Period for 2016 is now closed, you may qualify for a Special Enrollment Period for qualifying events at any time. The Annual Open Period for 2017 coverage opens no later than November 1, 2016. There are choices for individuals and families, including those who might not have had health insurance before.
You may be eligible for financial assistance from the government. The amount depends on your income and family size. Try our financial assistance estimator to find out if you might be eligible.
If you receive financial assistance from the government, you may be able to purchase your health insurance through the Health Insurance Marketplace (you may hear it called the “exchange”) or directly from a health insurance company. When you visit your state’s exchange, you’ll find out if you qualify for financial assistance from the government. If you qualify, you can buy directly on the exchange – your cost should reflect any financial assistance from the government that you may receive. Many states also allow you to apply your financial assistance from the government to a plan you buy directly from a health insurance company.
The next Annual Open Enrollment Period to buy health insurance for yourself or your family begins no later than November 1, 2016 and continues through January 31, 2017. (To be covered beginning on January 1, you must enroll on or before December 15, 2016.) If you have a qualifying life event, such as marriage, divorce, having a baby, or loss of a job, you may purchase a plan during a Special Enrollment Period. Special Enrollment Periods are generally in effect for 60 days following the onset of the qualifying event. Some people may also be eligible for free or very low-cost coverage through Medicaid and the Children's Health Insurance Program (CHIP).
Since January 1, 2014 most individuals are required to have health insurance. So if you already have insurance you won’t be required to do anything.
Most existing health insurance plans qualify under the law. If you have health insurance through your employer, for example, you do not need to get new health insurance. Some, but not all, individual health insurance plans may also be grandfathered.
These grandfathered plans count as health insurance under the new law, also. But grandfathered plans do not have to include all of the new healthcare law’s benefits and protections.
You can check with your health insurance company to find out if your plan is grandfathered and how its features compare to the new law. (You can check with your local Blue Plan)
Some individuals may have a “grandmothered” plan.
Grandmothered health plans were in effect on or before October 1, 2013 and have been given a special allowance to remain available to those who want to keep their existing coverage for an extended period. Grandmothered plans, also known as “transitional policies,” may not be available in all states and may not include all of the new healthcare law’s benefits and protections. Check with your health insurance company to find out if your current plan is grandmothered (is a transitional policy), and how its features compare to the new law.
As of January 1, 2014 most people must have health insurance or pay a penalty (unless they qualify for an exemption, e.g. religious exemptions or are members of Indian tribes). Some “transitional” health plans in effect before October 1, 2013 have been “Grandmothered” which will allow members to keep existing coverage for an extended period. Or, if you have a Qualifying Life Event, you may purchase coverage through a Special Enrollment Period if you need coverage before January 1. Short Term Health Insurance Plans are available if you are experiencing a gap in employer coverage, can't afford COBRA, waiting for employer coverage to begin, recently graduated and unemployed or age 64 and about to retire, but not yet eligible for Medicare. Contact your local BCBS Company for details.
When you buy health insurance, you’ll have two kinds of costs. The first – the premium – is easy to predict since it’s the same every month. The other kind of payment – usually called “out-of-pocket” – depends on the actual care you receive. Knowing how much you can spend on health insurance each month with considerations for how much you will pay each time you receive care will help you narrow your choices.
Your first cost is your monthly premium. It’s what you pay each month to have health insurance. You pay it whether or not you see a doctor or receive any medical care. Your premium is the same amount every month, so you’ll always know what to expect. And depending on your income and family size, you may be eligible for financial assistance from the government to help lower your costs.
It’s important to understand, though, that – just like other bills go up over time – your premium may rise when it’s time for you to renew your health insurance next year.
The second kind of cost is your out-of-pocket costs. For example, it’s what you pay out of your own pocket when you visit a doctor or get a prescription filled.
These can be hard to predict, since they depend on the care you actually receive. But generally, many health insurance plans have a limit on how much you could pay out-of-pocket for covered services in a benefit year. This limit is called the annual out-of-pocket maximum.
There are typically three kinds of out-of-pocket costs. But it’s important to remember that health insurance plan details vary – not every plan includes all types of out-of-pocket costs.
Choosing a health insurance plan that fits your budget means finding the right balance of premium and out-of-pocket costs.
Remember that your premium is simply the amount you pay every month to have health insurance, even if you don’t visit a doctor or fill a prescription. Most health insurance plans require you to pay out-of-pocket costs when you visit the doctor, fill a prescription, or get other care. You’ll want to think about how much you can afford to pay each time you receive care – or the total cost if you or a family member experienced a serious, unexpected health problem.
If you know you’ll need frequent medical care – or major care like surgery – you may want to explore a gold or platinum plan that covers a higher share of those expenses. But if you anticipate nothing more than routine doctor visits, you may be more interested in a bronze or silver plan with lower premiums that still helps reduce your costs if you have a major, unexpected illness or accident. Think about the financial consequences of large, unexpected out-of-pocket costs during the year. What would an accident or surgery do to your financial situation?
Here’s a good rule of thumb: plans with low premiums usually have higher out-of-pocket costs. To lessen the risk, consider spending more on your premium in exchange for a lower maximum on the total out-of-pocket costs you could pay in a year. Remember, if you are worried that you can’t afford health insurance, you may be eligible for financial assistance from the government.
At the emergency room, Teresa got X-rays and had her ankle placed in a brace. The total medical cost came to $4,900. Teresa pays a $200 copay at the emergency room, but she may still have additional costs associated with her care.
Teresa reaches her $1,500 deductible during her ER visit. Once Teresa reaches her deductible, her plan's coinsurance kicks in. Teresa pays 20% (her coinsurance) of the remaining ER medical cost—Teresa's insurance pays the remaining 80%.
Teresa pays a copay at her regular doctor and her insurance covers the rest of the visit's medical cost. If Teresa reaches her $3,000 out-of-pocket maximum during the remainder of the benefit year, insurance will pay 100% of her covered medical costs.
As of January 1, 2014, most people must have health insurance or pay a penalty (unless they qualify for an exemption, e.g. religious exemptions or are members of Indian tribes). Some “transitional” health plans in effect before October 1, 2013 have been “Grandmothered,” which will allow members to keep existing coverage for an extended period. Or, if you have a qualifying life event, you may purchase coverage through the Special Enrollment Period. You also may consider a Short Term Health Plan if you are experiencing a gap in employer coverage, can’t afford COBRA or meet other criteria. Check with your insurance company for details.
Beyond the security that health insurance provides you and your family, there are several things you can do to make sure you're taking full advantage of your health insurance plan.
AskBlue is here to help you. If you are trying to understand the kinds of costs you will incur, such as premium or out-of- pocket costs, visit the Figuring Out the Costs section. If you are interested in the different types of coverage in the exchange, including the so-called metallic levels e.g. the bronze, silver or gold levels of coverage, visit the Choosing a Plan section. Or, if you are trying to decide between a PPO, or an HMO or other types of health plans, AskBlue has a handy summary that can assist you. And finally, the Glossary section will provide definitions for the most commonly used terms.
However, for a more personalized assistance, click Shop for Insurance to visit your BCBS company's website or to talk to a customer service representative.
Your employer will likely have someone in its HR department that can help you on this transition period. It is also a good idea to navigate our AskBlue website to learn about options available to you, including whether you and your family may qualify for financial assistance from the government. You also may contact your local Blue Cross Blue Shield Company to see how easy it might be to keep your current level of health coverage. You can visit your local BCBS Company’s website or talk to a customer service representative to get information about how to purchase health coverage directly instead of through your employer, and how much it will cost.
For millions of Americans, the new healthcare law means a chance to get health insurance that offers real security and stability. But choosing health insurance that’s right for you and your family means doing a little homework first.
* Refers to a combination of deductibles, copays, and coinsurance.
Health Maintenance Organizations (HMO) generally only pay for care you receive in the network, except for emergencies. Typically, you choose a primary care physician who will refer you to other doctors in the network, such as specialists, when medically necessary.
Preferred Provider Organizations (PPO) usually pay for out-of-network care, though you will pay more for that care. You don’t have to choose a primary care physician, and you can see a specialist without a referral when medically necessary.
High Deductible Health Plans (HDHP) are generally a type of Preferred Provider Organization where you pay more out-of-pocket costs before health insurance begins to pay. In exchange, your monthly premiums are lower. For 2016, the maximum out-of-pocket cost is $6,550 for an individual and $13,100 for a family.
Exclusive Provider Organizations (EPO) may pay for some care you receive outside the network, though you will pay more for out-of-network care. EPOs may require you to choose a primary care physician and get a referral before you see a specialist.
Point-of-Service Plans (POS) allow you to visit doctors outside the network, though you’ll pay more. They usually require you to pick a primary care physician from a network. Point-of-Service plans also require you to pay for care when you receive it, and premiums may be higher than traditional HMO plans.
Catastrophic Plans are only available to people who are under 30 years old; or do not have access to affordable coverage. They are designed to offer lower-cost protection against “worst-case scenarios.” These plans have high deductibles, and unlike other plans, they cover essential health benefits only after you’ve met certain cost-sharing requirements. Another important difference is that they cover only three primary care visits.
Although the list below doesn't cover every possibility, it’s a good "rule of thumb" for understanding when to go where. When in doubt, call a healthcare professional.
There's no "one size fits all" answer. But a good place to start is by thinking about what you and your family need and want from your doctor. Some good questions to ask include:
For information about how to retain your Blue coverage, you may Call Blue, toll-free, at 1.888.630.BLUE (2583). Just enter the five-digit ZIP code for your new home address and you will be connected with a sales representative at your new Blue Cross Blue Shield company who can help you. Each Blue Cross Blue Shield company is independently owned and operated, and BCBS companies are located in all 50 states and DC and Puerto Rico. To ensure you do not experience a break in coverage, ask how your coverage information can be shared with the new BCBS company.
If you would like to look for different health insurance options for 2017, you can do so in a variety of ways: Directly from your Blue Cross and Blue Shield company, through a broker or agent, or by returning to the online marketplaces. There are many Blue Cross Blue Shield coverage choices to choose from, and your Blue Cross Blue Shield company will help you find the one that’s right for you and your family.
Your income and family information needs to be updated with the government by December 15. If you do nothing, your current coverage will remain in place after January 1, 2017, but you may not be getting up-to-date financial assistance.
In most cases, no. But if you deliberately put false or incomplete information on your health insurance application, your insurance company may have grounds to cancel your coverage. And if you don't pay your premiums, your insurance company has the right to cancel your coverage.
If your health insurance company notifies you that it's dropping you, you have at least 30 days to appeal the decision. The levels don’t mean a plan is “good” or “bad.” They tell you the average percentage of your essential health benefits the plan will cover during the year. (Remember, all plans on the exchanges must include the essential health benefits, but you may pay out-of-pocket when you receive some of the services.) You may also want to compare premiums and out-of-pocket costs of plans within the same level.
No, this money can only be used to purchase a pre-selected, specific range of health plans offered by your employer. It may be a good idea to contact your HR department to help you decide which option is best for you.
Yes. However, if the employer’s health plan, including the HRA, meets affordability and minimum value standards, and you choose not to enroll in your employer's plan and you enroll in a qualified health plan through a marketplace instead, your participation in a group health plan means you will not be eligible for financial assistance from the government to help pay for your marketplace coverage.
Most people get health insurance through their employers, directly from a health insurance company, or through the government (like Medicare or Medicaid). But the new healthcare law offers you and your family another place to buy health insurance – the health insurance exchanges (for example, the Health Insurance Marketplace run by the federal government).
You can also purchase directly through your local Blue Plan. Before you start shopping on the exchanges or directly through your local Blue Plan, gather information about your household income – the money that everyone in your household earns. You’ll need this information to find out if you’re eligible for financial assistance from the government.
Next, make sure you’ve explored all of your health insurance options. And remember, you may be eligible for help through other government programs:
When you sign up on an exchange or directly through your local Blue Plan, you’ll find out if you qualify for one of these government programs.
Small businesses can also offer health insurance through the Small Business Health Options Program (SHOP) exchanges. So if you work for a small company that hasn’t offered health insurance previously, ask your employer about its health insurance options available for you.
If you think you can’t afford insurance on your own, find out how you may be eligible for financial assistance from the government. When you shop for health insurance on the exchanges or through some local Blue Plans, you can find out right away if you’re eligible for financial assistance from the government. This assistance is designed to help lower your monthly premiums. You may also qualify for lower out-of-pocket costs when you receive medical care, like visiting a doctor or filling a prescription.
To sign up, you must live in the United States and be a U.S. citizen (or be lawfully present).
You’ll need to provide the following information about yourself and your family to complete the form:
For full information, visit healthcare.gov.
You can see if you qualify for financial assistance from the government, which may help lower your costs.
You can compare plans from multiple health insurance companies based on their levels of coverage, a new way to make “apples to apples” comparisons between plans.
Of course, you can still shop for a plan directly from a health insurance company, and, in some cases, do so with financial assistance from the government.
Under the new healthcare law, some states will offer a Health Insurance Marketplace and, for the states that do not, the Federal Government will offer a Health Insurance Marketplace (you may hear a marketplace called an “exchange”). The marketplace, or exchange, is another way to shop for health insurance, with a website where you can compare different options. Tools on the marketplace allow you to compare plans from multiple health insurance companies by price, benefits, and other factors that may influence your decision, so you can select a plan that’s right for you and your family. You can purchase your health insurance right on the website, too. All health insurance plans you see on the marketplace will have to explain what you get and what you’ll pay, in plain language.
Anyone who purchases health insurance on their own can use the marketplace. If you are eligible for financial assistance from the government, you may need to purchase your health insurance on the marketplace to receive the assistance, though many states also will allow you to use your financial assistance from the government to purchase a plan directly from a health insurance company.
No. Without taking any action, you’ll be automatically re-enrolled in the same or a similar plan. However, it’s important to make sure you get the correct amount of financial help for 2017, so you may need to update your income or family information with the government. Act by December 15 to make sure everything’s up to date for the New Year. If you need help, you can count on us to help you through the process – just contact your local Blue Cross and Blue Shield company.
If you buy your own health insurance, your insurance company must give a rebate if it spends less than 80% of the premiums it collected on health care and quality improvement. This new requirement is often called the "80/20 rule."
If you are eligible for a rebate, you may get a check in the mail or you may get an automatic discount on your future premiums. If you paid your premium with a debit card, your insurance company may deposit your rebate into the bank account you used to pay the premium.
Important to remember: your insurance company’s performance on the 80/20 rule may change from year to year. So getting a rebate one year doesn’t mean you’re guaranteed a rebate the following year.
Yes, you can purchase an individual BCBS health insurance plan that fits your particular budget and needs. To find out what your options are, click Shop for Insurance to visit your BCBS company's website or to talk to a customer service representative. Alternatively, you can leave your contact information and the BCBS company will contact you to discuss coverage options.