For Support Call: 888­-704-8243

All posts by matrixia

What’s the difference between deductible, Copy and coinsurance?

Learning about the terminology related to health insurance can be very confusing, especially since it’s so important to understanding the benefits that you have and what you will be responsible for under your health plan. Without realizing what you are entitled to and what you have to come up with on your own, you could be facing an unpleasant surprise after visiting the doctor or getting a procedure done. This article is intended to help you answer one of the most common questions about deductibles, copays, and coinsurance.

It’s vital that you be aware of this if you already have health insurance, but it’s even more important to be informed if you are in the market for new insurance. These are  the finer details that can help you identify the plan you really need. With the launch of the healthcare reform known as the Affordable Care Act, it’s more important than ever that you educate yourself.

One of the most common terms related to your health insurance coverage is your premium. This refers to what you pay each month for the privilege of having healthcare coverage. Another important term is deductible, and this is usually one of the first numbers you will encounter. This is considered the amount that you must kick in first for your healthcare costs, before your insurance company will step in to pay their portion. Choosing a healthcare plan with a high deductible may not be worth it if you don’t hit that deductible to allow the benefits to kick in.

A co-pay and co-insurance are different than a deductible. These refer to deductible as well, so you can see why it’s so important to shop around and identify the right mix of deductible and premium as well. A co-pay is the routine cost for services you’ll need to pay at each doctor’s visit, for example. This is an amount for which your deductible does not apply, so bear in mind that your co-pays are not building you up to that deductible “cap” where the health insurance company kicks in. Your coinsurance, on the other hand, refers to the percentage that you will be responsible for after the deductible has kicked in. For major procedures, for example, you’ll likely be responsible for some portion of the treatment, and you’ll want to read the fine print in your insurance policy to determine this.

I have insurance through my employer- how will Obamacare affect that?

If you already have insurance through your employer that you like, you can keep it. If your employer doesn’t offer health insurance coverage that meets the minimum coverage standards, though, or if you do not have health insurance options through work at all, you can search for an appropriate plan on the health insurance exchange.

At the passage of the Affordable Care Act, the majority of people who already had coverage under an employer are eligible to keep it because those policies were grandfathered in. The reasoning behind this choice is that while there were many Americans who did not have access to quality plans prior to the implementation of the Affordable Care Act, it was recognized that there were also many individuals who currently had healthcare plans and employer options that they did like. There is no reason to change if you are still obtaining coverage under a plan that you like.

Since there have been so many changes in the marketplace, though, make sure you review your plan options through your employer. Many employers have opted to make changes in the provider or in the types of plans offered, so it’s always in your best interest to review those materials on a regular basis so that you are clear about the value and the mechanics of the plan.

If you do not have coverage through an employer-sponsored plan because you are not eligible for one, because you recently became unemployed, or through some other special circumstance, you may be eligible for coverage through the state health insurance exchanges. Note that outside of regular enrollment periods, you must meet an exception to qualify for coverage.

For the most part, if you have employer-offered coverage, you are considered covered. You could be eligible to switch over to Marketplace coverage, but you will lose out on the employer contributing towards your health plan. In many workplaces, your employers helps to subsidize the cost of your premiums. Switching over the marketplace coverage will mean that you might not qualify for lower premium costs due to your income. This all depends on the kind of coverage your employer offers, but if the plan is grandfathered in, it’s considered to be minimum essential coverage and you might not save anything by switching to the marketplace. You’ll lose out on premium savings that you could have met if you did not have the employer based coverage.

What if My Doctor is not taking my Covered CA Plan? What Are My Options?

Unfortunately, you may learn after opting in to a Covered California plan that your doctor no longer accepts that plan. Some individuals in California have faced this situation as a result of technical glitches, wherein their doctor was listed on the website detailing coverage details but wasn’t actually accepting the plan.

In those cases, you may be referred to a customer service representative to help you identify another in-network doctor to perform the procedures or services needed. Part of the reason that some providers are not accepting certain plans is because of the opportunities offered by Covered California. Since the health insurance exchange has added more competition into the market,insurance companies have had to go back to the drawing board to find effective ways to remain competitive themselves. In many situations, this results in controlling plan costs by limiting networks of providers. In fact, this trend is now new, but has simply been accelerated by the competitive nature of the Covered California exchange.

Another associated challenge is that doctors often move from one group to another or become affiliated with a bigger group, making it difficult to track down through a database whether a provider is actually accepting that insurance or not. Although doctors are often required to update the insurance company if they have moved to another group, that protocol is not always followed.

If you discover that your doctor is not accepting a Covered California plan, you may have to do some research on your own, especially if you are aiming to get covered for a specific medical need like a procedure. Although the online networks that identify providers might be a good starting point, they are not always entirely accurate, which is why you should spend some time making phone calls to identify other providers in your area that do accept your coverage. Remember that more than 80 percent of California doctors are actually included in the state healthcare exchange plans and a majority of state hospitals are included in the plans, but you may want to do some your own research and verification. Getting details in writing may also be helpful if you want to ensure that you are using your plan to the fullest. If you discover that the doctor you have been seeing is not in the network, contact your insurance provider to identify someone else.

Why is Kaiser Different From Other Providers?

If you are looking at your coverage options for healthcare for the next year, you might be considering Kaiser Permanente as an option. Compared to other providers on the California health insurance exchange, and depending on your exact location, Kaiser might be showing up as one of the more expensive healthcare options both for individuals and families.

While Kaiser offers plans with many of the same benefits as other California plan providers, they are a different type of company. This is because they are considered “truly integrated” with their own healthcare delivery system both in the state and around the country. They have their own clinics, hospitals, other essential plan components, and even their own healthcare professionals within their system. While for some this could be viewed as a professionalization and a standardization across their various forms of care, it can also make things more expensive. Another benefit of being structured like this is that the company is essentially able to provide all services to each of their plan members because of this extensive system.

The downside of that is that it can be expensive to maintain such a system, even when it has bene streamlined. Careful execution of a strategy like this and advance planning are critical for the company to get the most out of this but also for insured individuals to capitalize on the strengths of their plan. Plans like this are dependent on big enrollment, because the cost of enrollment, when spread out over so many individuals, can help to keep the costs reasonable and therefore present a sensible perspective on keeping so many facilities and providers managed under the Kaiser Permanent system. It’s a delicate balance, because sudden surges in patients and enrollment could even put a strain on such a system, but too low enrollment means that it doesn’t really pay off to have such a big system built in.

It’s important to know that there are many different plan options under Covered California and that the purpose of a health insurance exchange is to give you plenty of choices to determine the best fit for you and your family. One of the advantages of selecting a plan through Kaiser is that you’ll benefit from the standards and system already developed in-house. For some families, that could be a perfect fit. Remember that you can use the health insurance exchange to shop around.

Whats Cheaper? Buying plans on my own or buying COBRA insurance.

If you have been laid off or fired from your job, the amount of details you may be considering can be overwhelming. It can be difficult to figure out where to start, but health insurance should certainly be something you consider fixing right away. Typically, you’ll expire out of your employer sponsored coverage at the end of the month or billing period for that coverage.

Your employer is legally obligated to give you the option of continuing on with your existing plan at your own cost for up to 18 months after you leave your job. Shortly after leaving, you should receive sign-up details from your employer to learn more about what you’ll need to do if you plan to keep your existing coverage. On the plus side, COBRA can allow you to continue your coverage as you search for a new job or other options. On the downside, however, your coverage is likely to be extremely expensive.

Many people who are laid off or are fired find that the high cost of COBRA is not something they can afford being newly unemployed. Unless you have banked significant savings and are concerned about emergency care or services for an existing condition, COBRA may not really be an option for you. In addition to fronting the cost for your own care and your family’s care, your employer has the option to add on a 2% administration fee for continuing to manage the plan. Overall, the cost of keeping your coverage through COBRA can be far too much to make it worth it.

Thankfully, you do have another option, and that is getting coverage through the health insurance marketplace. Although enrollment periods for signing up in general are limited each year, being laid off from your job means that you could qualify for a special enrollment period for up to 60 days after your termination from your employer. You’ll need to provide all the information for your coverage, as well as your income level, in order to see what plans are available. Make sure you act sooner rather than later if you are concerned about a lapse in coverage causing serious problems for you or your family.

While it’s hard to return to normal life after being laid off, you need to act quickly to determine how you will be maintaining health insurance coverage.

I was laid off from my job and I lost my benefits. What are my options?

Finding out that you no longer have health insurance as a result of being laid off can be a confusing and frustrating experience. If you have relied on health insurance coverage through your employer in the past, you will lost it at some point after being fired, getting laid off, or voluntarily leaving your position. When this coverage ends tends to depend on your job, as some employers will keep your coverage through the end of the month or a different period if stipulated in your employment contract. The Affordable Care Act does not change your health insurance if you are laid off from your job, so you can expect to lose that coverage if this happens to you. If that’s the case, you have several options about how to proceed.

First of all, you may be able to continue coverage through COBRA, but some individuals find this very expensive. Your employer should provide you with the details about what it would cost to continue this coverage. Even though the price can be high, it may be worth it for you to retain this coverage for a period of time until you figure out your next move. Unless you were fired for gross misconduct, you are eligible to continue your plan through your employer for up to 18 months.

Your other options is to attempt to obtain coverage through the insurance marketplace. Open enrollment for the 2015 year begins on November 15, 2014 and will run through January 15, 2015. If you happen to lose your job outside of these specific dates, you may qualify for a special enrollment period. If this is the case, you have 60 days within which to apply for health insurance coverage from the date you lose your job.

When you apply for coverage through the health insurance marketplace, you will need to supply income details to determine if you are eligible for assistance and tax-sharing programs. Since the exchanges for health exchange are online, you should be able to learn everything you need to about the cost of care. The upside of being laid off in a non-enrollment period is that you may be able to get more personalized service in getting your plan activated if you require help.

Getting laid off is certainly difficult, but you do have options for continuing your coverage or purchasing your own coverage.

How long does it take to get the health insurance? When can we start?

At the close of March 2014, the open enrollment period ended for obtaining health insurance. This doesn’t mean, however, that you have no options to get covered. If you qualify for Medicaid or have someone who needs coverage under the Children’s Health Insurance Program, you may sign up for these services at any time year-round. If you meet the minimum qualifications, you’re eligible to sign up right away to being receiving those benefits.

Outside of the typical enrollment period, you may qualify for special enrollment if you meet any of the following criteria regarding qualifying life events:

  • Divorce or marriage
  • Adopting a child
  • Having a baby
  • Placing a child for foster care or adoption
  • Moving to a new residence
  • Exiting incarceration
  • Obtaining citizenship
  • Losing healthcare coverage at the end of a 2014 individual policy plan, expired COBRA benefits, aging out of a parent’s plan, loss of job-based coverage, or losing eligibility for CHIP or Medicaid.

It’s important to know that voluntary opting out of existing coverage may not necessarily qualify you for a special enrollment period. If you are eligible to apply under a special enrollment period, you might be able to get reduced out of pocket costs or premium tax credits that keep your overall costs down.

If you apply for a Special Enrollment Period and get denied or if you believe, based on reading the above statements, that you are not eligible for a Special Enrollment period, you do have options. You can appeal an existing denial. Furthermore, if you are not eligible or continue to be denied, the Open Enrollment period for 2015 will start on November 15, 2014.

Looking into coverage options for your 2015 plan is a good exercise to begin as soon as possible so that you are aware of what is the best plan for you. Putting in some research on your end will clue you in to the various prices for programs in your state and your official coverage plan will begin on January 1, 2015. Once your coverage becomes active, you are eligible to reap the full benefits of whatever you have selected. This includes going to the doctor, filling a prescription, obtaining preventive care services, or visiting the emergency room. If you already have coverage, you’ll also be able to review your current plan and determine whether you want to change or not.

Can a pregnant person get health insurance under the new law?

One of the most common questions surrounding health insurance under the Affordable Care Act is whether there are certain circumstances or conditions that might prohibit a person from being able to get the health insurance he or she needs. There are numerous ways that women benefit from new coverage requirements under the new law, and maternity care is one of those benefits.

In the individual insurance market prior to the Affordable Care Act, maternity care was routinely excluded for one reason or another. Before the Affordable Care Act went into place, just over 10 % of plans provided access to these services. Even where it was offered, it was frequently considered inadequate as a result of extremely high deductibles (many of which may have cost as much as the total amount of a birth, for example) or waiting pools. Following the full implementation of the Affordable Care Act, however, more than 8.5 million women will have gained access to maternity care through small group and individual plans.

Remember that under this same law, no individual can be denied coverage as a result of a pre-existing condition, either. One such example of a “condition” that result in denial of coverage in the past related to pregnancy was a history of Caesarean sections. Under the new regulations and rules, many more women will gain access to not just maternity care but preventive services. Women will have the peace of mind that regardless of any past conditions or concerns, they are eligible for healthcare coverage through the marketplace.

Another barrier that has been broken through the enactment of the Affordable Care Act is that women will gain more control over their healthcare. Being able to choose a primary care physician and any pediatrician for children is a major benefit, but referrals to see an obstetrician/gynecologist are no longer mandated, either.

Not only are women who are pregnant eligible to receive coverage under the new law, but new regulations have made it much easier to get critical care needed for themselves and for their children. Gaining access to affordable and quality healthcare will likely have far-reaching implications for women and their families across the country. Shopping in the healthcare market provides an array of cost-effective plans with critical coverage for women who are already pregnant or for women who plan to become pregnant in the future.

What’s the difference between HMO and PPO Plans?

Shopping around for health insurance is always a bit intimidating for first time buyers. There is so much important information to know and so many different kinds of plans with different benefits, when looking at all of the information floating around cyber space, it can become a bit overwhelming.

If you are self-employed or working your first full-time job with benefits, open enrollment for your company’s insurance plan can feel super stressful. After all, you don’t have time to wade through a sea of websites to figure out which plan is best for you and your budget. Besides that, there are all these funny little acronyms for things and if you only knew what they meant you’d feel a little more comfortable when it came to picking your plan.

The majority of insurance plans fall into two categories: an HMO or a PPO. These plans are similar in many respects, but they also have a number of important differences, and depending on your situation, one might not be as good for your needs as the other.


HMO stands for “health maintenance organization.” This type of plan connects you to doctors, specialists, and facilities that are part of a “provider network.” One of the features of an HMO is paying a co-pay, which is usually a small fee, to visit your physician or for a trip to the hospital.

Another perk of HMO plans is that they typically have a lower monthly premium than other types of plans. While these are really good benefits of this insurance program, there are some drawbacks.

HMO insurance policies are not very flexible. If the doctor that you visit is not a part of the provider network, you will need to change physicians or pay out of pocket to see your current doctor.

If you should need non-emergency care that is provided for you by a doctor or specialist not in the network, the insurance will likely not cover the cost of the treatment.

In general, HMOs are a great plan for those who are looking for quality care with the lowest possible cost. Be sure to research each program you are being presented and check with your doctor to make sure they are part of the network before signing up.


A PPO is a “preferred provider organization” plan. These plans, like HMOs, put you in a contract with health care professionals that are in a provider network, except PPO plans will cover some of the cost for care that is provided by doctors outside of your network.

Another similarity between HMOs and PPOs is the low monthly premium. The difference being that with a PPO, out-of-network care will be a bit more expensive. HMOs require you to have the permission of your physician to see a specialist, but this is not required with PPO insurance.

Just like HMOs, there are some disadvantages to a PPO plan. The biggest one being the increased cost in the form of a deductible for out-of-network care. This is still a minimal hang up, as the HMO does not cover any of the cost for this type of care.

Also, if your physician charges rates that are a bit higher than what the insurance plan deems to be reasonable, you may be left with additional out-of-pocket costs.

Both of these insurance plans offer great services and premium costs, so it is up to you to decide which one is best for your situation. If your doctor does not take the HMO plan, it might be wise to go with the PPO.

What Is Professional Liability Insurance and Do I Need It?

Running a business is not for the faint of heart. There are mountains of risk involved, which is why entrepreneurs always tend to be the brave and the bold of society. Successful business owners experiment with new ideas, knowing full well that failure is a possible outcome, and it could cost them a lot financially, yet they march on into the unknown.

While taking chances is simply a part of life for business owners, there are certain kinds of risk that should be avoided if possible, which is where professional liability insurance comes in handy. If you are new to owning a business, you might not have heard of this insurance before. Here is a quick guide to explain some of the basics of professional liability insurance that will demonstrate how valuable one of these policies can be to your company.

What is Professional Liability Insurance?

This type of insurance product is designed to help protect you and your company from being sued by clients and customers as a result of any advice, expertise, or services rendered. A client could say that the service or advice you offered harmed them in some manner, due to an act of negligence, some kind of error, or an omission of important information.

Without having the proper protection, a lawsuit could be a serious hit to your profit margin and possibly put you out of business.

Who Needs to Buy This Type of Coverage?

Not every type of business owner needs to have professional liability insurance. Retail businesses that sell a tangible product of some kind would not need this coverage. However, if your business offers any type of advice, recommendations, or services, you need to purchase a policy in order to help offset the risk associated with certain lines of work.

A few good examples of professions that need this type of insurance would be financial professionals like an advisor or insurance salesperson, architects, real estate agents, accountants, and dentists.

Why You Need to Buy Professional Liability Insurance

Anyone who is a professional in a specific industry is expected to have expert-level training and knowledge of their area of expertise. As an expert in your field, your customers count on you to provide services that match your qualifications, and any time a customer feels you have failed to do that, it puts you at risk for legal action.

A lawsuit is bad for business all-the-way-around. Court costs, settlements, and bad publicity could force you to shut your doors. Having professional liability insurance will help protect you from the financial devastation of a legal claim, enabling you to keep your company up and running.

What Does This Insurance Cover?

Professional liability insurance protects you from several types of risk. The insurance will protect you from cases involving a faulty service. A faulty service is simply an error that you made when providing your services or advice to a client. It will also cover instances where you may not have performed a service that you promised to perform for a customer. This is known as an omission.

One of these policies helps cover court expenses, such as your legal defense, and will also cover the cost of damages awarded to your customer, up to the policy limit.

A professional liability insurance policy is considered to be specialty coverage, which means it is not included in your business owner insurance. As you can see, running a business, especially one that offers advice or professional services, puts you at great risk should a client feel dissatisfied with your work. Rather than take the risk of being sued and having expenses come out of pocket, purchase one of these plans and rest a bit easier knowing that if something should happen, your business is protected.