What is an out-of-pocket limit?
An out-of-pocket limit (or max) is the most you have to pay for covered services in a plan year. After you spend this amount on deductibles, co-payments, and co-insurance for in-network care and services, your health plan pays 100% of the costs of covered benefits. Here’s how co-insurance and out-of-pocket max works: Imagine you have […]
What is a premium?
A premium is the monthly cost of your health insurance. You’ll pay your premium every month, on a set date, regardless of if you go to the doctor or not.
What is a deductible?
A deductible is the amount you pay for covered healthcare services before your insurance plan starts to pay. Here’s how a deductible and co-payments work: If you go to the doctor, you might pay $30 at the front desk when you check in (co-payment) and then have a checkup and some tests that cost $425. […]
What’s always covered in my health insurance plan?
Under the Affordable Care Act, individual plans must cover preventative care — which includes your annual check-ups, preventative tests, and immunizations — at zero out-of-pocket cost to you. Additionally, all individual plans must cover the following essential benefits: Ambulatory patient services (outpatient care) Emergency services (trips to the ER) Hospitalization (inpatient care) Maternity and newborn […]
What happens if I see a doctor outside of my network?
It depends on your plan. Generally, Preferred Provider Organizations (PPOs) will pay a portion of any care you receive from an out-of-network provider while Health Maintenance Organizations (HMOs) will not. Exclusive Provider Organizations (EPOs) may or may not. For more information about your plan’s out-of-network coverage, consult the plan’s summary of benefits.
What is Open Enrollment? What if I miss it?
Open enrollment is a specific time period each year when you can enroll in, change, or waive your health insurance benefits. There are two types of open enrollment periods to be aware of: ACA Open Enrollment: This is the nationwide enrollment window for individual health insurance, typically running from November 1 to January 15. Employer […]
Can I be denied coverage for a pre-existing condition?
No — you cannot be denied coverage for a pre-existing condition. Under the Affordable Care Act (ACA), health insurance plans are required to cover all applicants, regardless of medical history. This means insurance companies cannot deny you coverage, charge you more, or refuse to cover treatment for any condition you had before your coverage started.
What is a metal tier?
All health insurance plans in the market are broken into four metal tiers: Bronze, Silver, Gold, and Platinum. These metal levels differ in how the costs of your healthcare are split between you and your insurance company. Generally speaking, plans with higher premiums have lower annual deductibles. Plans with lower monthly premiums tend to come […]
How does my monthly premium get paid?
Once you sign up for health insurance through BEN360, you don’t have to worry about paying the insurance company directly. Benafica automatically remits your monthly premium on your behalf. If your plan costs more than your employer’s ICHRA contribution, we work with your employer to deduct the difference from your paycheck, typically on a pre-tax […]
How can I make sure my prescriptions are covered?
Insurance plans typically classify drugs into tiers: Tier 1 to Tier 4. You can find more information on how much you will pay for each drugs in each tier in your plan’s Summary of Benefits. Tier 1 drugs are generally generic versions of brand name drugs and require the lowest copayment while Tier 4 drugs […]