Greetings! I'm Tina. I'm here to answer some frequently asked questions for you.

  • Health insurance is a service that helps cover the cost of providing care to help keep you healthy, when you become sick or injured, or if you have a chronic condition
  • It's an agreement between you and an insurance provider to share the cost of care
  • It protects you from very high expenses when you need health care
  • Without health insurance, it would become very expensive to pay for care if you were to become injured or ill
  • It can give you access to preventive care (routine checkups, screenings, and vaccines) to help you stay well
  • It can reduce the cost of some of your prescription medicines
  • If you can afford health insurance but choose not to buy it, there is a fee (or penalty) that you will have to pay
  • Anyone can get health insurance coverage—there's an option for everyone
  • Even if you have an illness or disability, coverage is available
  • If you don't think you can afford health insurance, the government has options to help you if you qualify

Find out what health insurance might be right for you

  • Your employer might offer Employer-Sponsored Insurance (ESI)
  • The state or federal government has programs for some groups of people (American Indians and Native Alaskans, people with certain diseases or health conditions, pregnant mothers, etc.)
  • Medicare
  • Medicaid
  • Military
  • On your own
    • Private insurance companies
    • The Health Insurance Marketplace

Learn more about your options

  • There is a period of time called open enrollment. During this time, you can sign up for insurance for the upcoming year
    • For employers, this is often in the fall
    • For the Health Insurance Marketplace, you can enroll during the open enrollment period - see www.healthcare.gov for specific dates
    • Some government programs like Medicaid allow you to sign up at any time
    • Individuals may also qualify for Special Enrollment Periods outside of Open Enrollment if they experience certain events.
  • You can also enroll in health insurance after going through certain changes in your life, called qualifying life events. These are opportunities to adjust your coverage to fit your needs
  • Examples of qualifying life events
    • Birth or adoption of a child
    • Death of a child or placement for adoption
    • Change in marriage status (married, divorced, legal separation, annulment)
    • Change in employment (hired for new full-time job, loss of job, retirement, etc)
    • Loss of coverage from private insurer

Learn more about when to sign up

  • Everyone will need to spend some of their own money on care, but the actual amount you pay for your health insurance depends on things like which plan you choose and how often you need care
  • Once you have paid a certain amount of money for care in a year (your deductible), most plans will help you pay for the cost of prescription medicines with a copay or coinsurance. If you have insurance, check with your provider for your prescription costs
  • If you don’t have health insurance, or have a plan that doesn’t cover prescription medicines, there are ways to lower your out-of-pocket costs
  • Since prescription medicines can have different prices at different pharmacies (including some that provide medicine by mail), comparing what you would pay at your local pharmacies might help you find a lower price. Click here to use a tool that helps you compare costs at different pharmacies in your area
  • Some drug companies help patients with the costs of their medicines. These programs are subject to terms and conditions, and not all patients will be eligible for savings
  • You may want to check if the drug company that makes your medicine offers a cost savings program for which you are eligible. Because these programs can be discontinued or your eligibility can change, you should not rely on them when selecting health insurance coverage
  • Savings offers on certain Merck medicines are available for eligible patients; please see the terms and conditions of the offer for eligibility requirements
  • If you do not have prescription-drug coverage and cannot afford your medicines, you may be eligible for free Merck medicines through the Merck Patient Assistance Program Inc. Get the facts about this and other programs from Merck. Visit www.MerckHelps.com
  • Helen's plan includes a $1,000 deductible. For the first $1,000 worth of health services, Helen pays all of the costs herself before her plan will begin sharing the cost of care with her. Some plans may share the cost of care with you for some services, even before the deductible is met, so check your plan's details to see how your plan is set up
  • Helen's plan includes a $15 copay for her generic prescription medicine. Once she has met her deductible for the year, each time Helen goes to the pharmacy to pick up her medicine, she pays a $15 copay
  • Helen needs minor surgery that will cost $6,000. Since she has already met her deductible and her plan includes coinsurance of 30%, she owes 30% of $6,000, which is $1,800. Her insurance company will pay the remaining 70%, or $4,200.
  • Out-of-pocket (OOP) costs are payments that you pay out of your own pocket
  • They include your deductible and any copay or coinsurance payments you make during the year
  • Even though you pay your premium out of your own pocket, the premium costs are NOT counted toward your out-of-pocket maximum
  • Only services and drugs that are covered by your plan contribute toward the OOP max. Also, remember that many plans will only consider care (office visits, tests, or procedures) from providers that are in the plan's network

There are a number of factors to consider when choosing a health plan. To figure out what coverage you might need, you may want to first ask yourself questions, such as:

  • Overall, how healthy have I been in the recent past?
  • Do my family members or I have any health conditions?
  • Am I beginning to experience any age-related health conditions?
  • Am I active or do I have an active spouse or children playing sports? The risk of injury might be higher for people with active hobbies like rock climbing, recreational sports, or even running
  • Do I see any specialists (like a podiatrist for foot problems or a neurologist for migraine headaches)?

Your answers will help you decide what features to look for in a plan.

Second, consider what options are available to you.

  • Am I a US citizen, US national, or legal US resident?
  • Am I 65 or older?
  • What state do I live in?
  • Can I get insurance through my job, spouse, parent/legal guardian?
  • How much money do I make per year?
  • Have I served in the US Armed Services?
  • Am I pregnant?
  • Do I have end-stage renal disease, Lou Gehrig's disease, a disability, or am I legally blind?

Your answers will help you decide where you can get coverage.

You will also want to consider the cost of your options. Think about each plan in terms of expected monthly and yearly costs based on your health care needs.

One way to balance out costs throughout the year might be to choose a plan with a higher monthly premium. These plans often have lower deductibles, allowing you to begin sharing the cost of care with the insurance company earlier in the year with copays and coinsurance.

If you can afford to pay more on your own each time you need care (and are generally healthy), a plan with a lower premium and higher deductible might be an option for you.

Think about what you can pay for care, and when you might want to pay these costs. When comparing plans, consider asking yourself:

  • What can I afford to pay as a monthly premium, even if I don't need care?
  • How often do I think I may need to visit the doctor or a specialist?
    • Are these doctors in my plan's network? If not, what will it cost me to see them?
  • How often do I think I may need prescription medicines?
  • How much can I afford to pay on my own before health insurance begins sharing the cost of care? (deductible)
  • What will it cost me out of my own pocket each time I need care? (copay, coinsurance)
  • What is the maximum I will have to pay out of my own pocket for covered services in a year?

Your answers will help you decide how much coverage you need. For additional information see www.healthcare.gov.

Facebook Twitter Pinterest