Health Insurance 101 With J.C. Lewis Insurance Services

If you are a young adult living in Northern California between the ages of 18 to 25, it is quite possible that you are looking to get your own insurance for the first time.

There are a few reasons why this may be the case.

If you are not on your parent’s insurance, or if they are not insured, you may be looking to get your own coverage. However, keep in mind that you can legally remain on your parent’s health insurance until you are 26. This was a change that was implemented by the Affordable Care Act when it became effective back in March 2010.

Another scenario may simply be that you have chosen to purchase your own health insurance either because your employer does not offer it, or you don’t want what is being offered by your company.

By the way, you should also know that businesses that have 50 or more employees are required to offer affordable health care coverage options for employees. And, the state’s health exchange marketplace, Covered California, points out,

“Small business owners with fewer than 50 full-time employees are not required to offer health care coverage to their employees. However, you should know that if a small business with fewer than 50 full-time employees does offer coverage, then that coverage must comply with the requirements of the ACA.”

And, thirdly, it’s quite possible that you are self-employed either as an independent contractor or a young entrepreneur and business owner. In that case, you most likely would have to find your own health plan.

Regardless of whether you stay on your parent’s policy, go with a plan offered by your employer, or choose to find your own health insurance plan, you still need to have coverage.

CONSIDERING CALIFORNIA HEALTH INSURANCE

Since 2020, Californians are required by state law to have health insurance. This law is referred to as an “individual mandate” because all individuals in California are mandated to be covered by health insurance.

As a healthy, younger person possibly still unmarried, you may consider medical insurance unnecessary. However, no matter how healthy and fit you may be, things happen. Much like auto insurance, while you don’t make use of it every day, when you’re in an accident, you certainly want it.

Similarly, if you were to trip while going down some stairs and break your arm, you’ll be glad to have health insurance. That’s largely because even the basic cost for treating a fractured arm can be over $6,000 without insurance. And that’s for a simple break. If you have more complex injuries, you may be billed much more.

That’s because everything associated with medical care costs money – and usually quite a bit of it.

For example, any trips in an ambulance, medications given, medical equipment and supplies used, X-rays and other imaging services, as well as the doctor’s and nurse’s time all add up very quickly. And if you must stay in the hospital for even a short amount of time, the costs add up even faster.

In fact, the average cost of a hospital stay can be as much as $10,000 a day.

And along with an affordable health insurance plan and policy, it would wise to obtain vision insurance, dental insurance, and comprehensive prescription drug coverage, as well.

THE THREE MOST COMMON HEALTH INSURANCE PLAN TYPES

Strictly speaking, there are more than half a dozen different types of Marketplace health insurance “plans” available in California, including what is known as a high-deductible health plan, or HDHP, which is a health insurance policy that has a lower monthly premium and a higher deductible. These are more popular with younger members and are often paired with Health Savings Accounts or an HSA.

Marketplace health insurance plans are designed to meet diverse needs. The three most common plan types, however, are PPO, HMO, and EPO plans. Here is a brief explanation of each:

PPO, or Preferred Provider Organization, is a type of health plan that allows you to pay less if you use providers in the plan’s network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost. Members have a yearly deductible they’ll be required to meet before coverage begins for their medical bills, along with a monthly premium. In addition, there is also a copayment for certain services.

A Health Maintenance Organization, or HMO, is a type of health insurance plan that typically limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. On the other hand, however, members usually have lower out-of-pocket.

In an HMO, visits to specialists require a referral from their PCP, or Primary Care Provider. Although HMO members typically have a copayment for services, they may not be required to pay a deductible before their coverage starts.

EPO, or Exclusive Provider Organization plans are similar to HMO in that services are covered only if you use doctors, specialists, or hospitals in the plan’s network except in the case of emergencies. There is typically a lower premium than with a PPO offered by the same insurer. With an EPO, you may have limited choices for your health care providers although likely more than through an HMO.

HEALTH INSURANCE MONEY TALK 101

All health insurance involves costs. While those costs can be significantly lowered with a subsidized health plan purchased through the state Marketplace, Covered California, there will always be costs, nonetheless.

Here is a basic overview of common costs associated with health insurance coverage.

What are premiums in health insurance?

This is the monthly cost that you will pay for your health insurance regardless of whether you use your coverage or not. While it is the primary cost most consumers tend to look at when choosing a plan, along with a premium, you will usually have to pay other costs such as an annual deductible, copayments, and coinsurance.

If you qualify for a Marketplace health plan, you may be able to lower your premium costs with a tax credit.

What are deductibles in health insurance?

This is the amount you pay for covered health care services before your insurance plan starts to pay. If your plan has a $2,500 deductible, for example, you will pay the first $2,500 of covered services yourself. This is quite similar to the deductible you may have in your auto insurance.

After you have paid your deductible, however, you then pay only a copayment or coinsurance for covered services and your insurance company pays the rest. Generally, plans with lower monthly premiums have higher deductibles, while health plans with higher monthly premiums will have lower deductibles.

What is a health insurance copay?

Copayments, or copays, are a fixed amount ($15 or $20, for example) that you are required to pay for a covered health care service after you’ve paid your deductible.

An example might be a standard office visit. If your health insurance plan’s allowable cost for a doctor’s office visit is $150, your copayment for a doctor’s visit might be just $20. If you haven’t met your deductible yet, you would pay the full allowable amount for the visit of $100. If, however, you’ve paid your deductible you would only pay $20, often at the time of the visit.

Typically, health plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have lower copayments.

What is coinsurance?

The percentage of costs of a covered health care service that you may be required to pay after you’ve paid your deductible, often 20 percent in most cases.

According to the website at Obamacareandaca.com,

“Not all medical services are subject to coinsurance, and not all Obamacare plans come with a coinsurance requirement. Generally speaking, more expensive or higher metal-level plans (like platinum plans) may not require you to pay coinsurance. Coinsurance should not be confused with other form of cost-sharing such as copays or deductibles.”

HOW TO GET HEALTH INSURANCE

The good news is that getting health insurance in California is actually quite easy.

One popular approach is to simply apply for health insurance from The Marketplace, also known as Covered California. The healthcare Marketplace, also known as The Health Insurance Marketplace or simply The Marketplace, was established by the Affordable Care Act as a means to extend health insurance coverage to uninsured Americans.

Many states offer their own marketplace, including California, which can be found at Coveredca.com.

Through Covered California, individuals can apply for health insurance during what is known as Open Enrollment. This is a window of time when employees have to choose or change their coverage for the coming year. For example, Open Enrollment for 2023 starts November 1, 2022, to get health insurance from The Marketplace.

If you are currently unemployed, you may be wondering how to get health insurance without a job?

The good news is that this is a real possibility with Covered California. As their website states, people who are unemployed may be able to get an affordable health plan through the state’s Marketplace based on their household size and income.

Another option is qualifying for free or low-cost coverage through Medi-Cal.

GETTING HEALTH INSURANCE WITH THE HELP OF J.C. LEWIS INSURANCE

At J.C. Lewis Insurance we want to be your insurance partner and we offer quality health insurance plans only from the leading health insurance carriers licensed to do business in California.

We are a family-owned and operated health insurance agency located in Sonoma County, California. We specialize in finding and managing medical insurance plans not only for individuals, but for families and small businesses, as well, and we are licensed and certified by each insurance carrier we represent.

Finding the right health insurance plan in California can be challenging and there are many options to choose from. For example, if your employer does not offer health benefits, an individual plan may be the best option for you.

At J.C. Lewis Insurance we understand that when considering different health insurance options, there will likely be many questions and concerns. And we invite you to bring your questions about health coverage insurance to us and you can be assured that JC Lewis Insurance Services will help you find the right solutions for your health insurance needs.

So, call us today for more information or request a quote online.