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How Insurance Works

How Insurance Works

At the most fundamental level, all health insurance functions the same way. The insurance company collects premiums and pays out benefits while members pay premiums and collect benefits. The process of submitting claims and receiving payments varies by policy type along with the specifics of what is and is not covered.

How Can I Find Out about Specific Policies?

All issuers of health insurance are required to provide consumers with clear, consistent and comparable information about their health plan benefits and coverage—called a Summary of Benefits and Coverage (SBC).

The SBC is like a nutritional label for a health insurance plan.  The eight-page form displays information about a health plan in a simple question-and-answer format.  It answers questions like:

  • What is the overall deductible?
  • Is there an out-of-pocket limit on my expenses?
  • Does this plan use a network of providers?
  • Are there services this plan does not cover?

Explore Your Options

Plans vary by state. Find out which ones are available where you live.


How Is Individual Health Insurance Different from Group Coverage?

The primary distinction between group coverage and individual health insurance is selection. People who receive health insurance through an employer-sponsored plan pick their plan from a short list of options. On the other hand, people familiar with purchasing health insurance on their own are used to choosing a health plan from a wide range of companies and policies.

Group coverage is typically available through your employer. Depending on your employer’s budget, you may pay some of your premiums or your employer may cover them entirely. In almost every circumstance, however, the employer will pay at least a portion of the cost. Typically, group plans cover employees regardless of pre-existing conditions.


When Can I Enroll in a Health Plan?

Usually health plans only accept new members during the open enrollment period. If you fail to sign up for benefits during the open enrollment period, you may have to wait until the next open enrollment period to choose coverage options unless you experience a qualifying event that makes you eligible for a special enrollment period. A Short Term  plan might also be appropriate if you miss other enrollment opportunities.


Choosing a Primary Care Physician

Choosing a primary care physician (PCP) is an important decision for you and your family. Not only does your PCP provide regular checkups and other non-emergency care, but she also refers you to specialists when required. The PCP may suggest general wellness practices, like exercise and healthy diet, and help you maintain those routines. When it comes to individual health insurance, having a PCP is vital to guarantee you stay as healthy as possible.


What Kind of Doctor Do You Need?

If you’re in good health, you won’t need to visit your PCP more than once or twice a year. Choosing a general practice physician as your PCP allows you to receive the routine care you need. It also helps you develop a reliable and lasting relationship with your primary care providers.

Also consider factors about the primary care practice:

  • Is the physician’s office close to home, work or school?
  • Can you call or email the doctor if you have treatment questions?
  • If you need a referral to a specialist, does the doctor work with a reliable network of physicians?

Your health should be a top priority. Choosing the right physician and practice is an important first step toward maintaining a healthy lifestyle. It only takes a moment to look over our networks and select a good primary care provider.

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