MEMBERS HEALTH INSURANCE EXCHANGE – FREQUENTLY ASKED QUESTIONS

Click on a question below to see the answer and more information on the topic or call us at 877-267-3752 and we will do the work for you!

What is individual and family health insurance?

Individual and family health insurance is a type of health insurance coverage that is made available to individuals and families, rather than to employer groups or organizations. Given the option, most people would prefer to have their employer provide group health insurance coverage. But, if this is not an option for you, it is still important for you to seek coverage. You may be pleasantly surprised with the variety and affordability of the individual and family health insurance options available.

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What kinds of individual and family insurance plans are available?

Individual and family health insurance plans are usually described as either "indemnity" or "managed-care" plans.  Put broadly, the major differences concern choice of healthcare provider, out of pocket costs and how bills are paid.  Typically, indemnity plans offer a broader selection of healthcare providers than managed care plans.  Indemnity plans pay their share of the costs for covered services only after they receive a bill (which means that you may have to pay up front and then obtain reimbursement from your health insurance company), There are several different types of managed-care health insurance plans.  These include HMO, PPO and POS plans.  Managed-care plans typically make use of healthcare provider networks.  Health care providers within a network agree to perform services for managed-care plan patients at pre-negotiated rates and will usually submit the claim to the insurance company for you.  In general, you will have less paperwork and lower out-of-pocket costs with a managed care health insurance plan and a broader choice of healthcare providers with an indemnity plan.

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How does a PPO plan work?

As a member of a PPO (Participating Provider Organization) plan, you will be encouraged to use the insurance company's network of doctors and hospitals.  These healthcare providers have been contracted to provide services to the health insurance plan's members at a discounted rate.  You typically won't be required to pick a primary care physician but will be able to see doctors and specialists within the network at your own discretion. You will probably have an annual deductible to pay before the insurance company starts cover your medical bills.  You may also have a co-payment for certain services or be required to cover a certain services or be required to cover a certain percentage (coinsurance) of the total charges for your medical bills. With a PPO plan, services rendered by an out-of-network physician are typically covered at a lower percentage than services rendered y a network provider.

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How does an HMO plan work?

Though there are many variations, HMO (Health Maintenance Organizations) plans typically enable members to have lower out-of-pocket healthcare expenses but also offer less flexibility in the choice of physicians or hospital than other health insurance plans.  As a member of a HMO, you will be required to choose a primary care physician (PCP).  Your PCP will take care of most of your healthcare needs.  Before you can see a specialist, you will need to obtain a referral from your PCP. With an HMO, you will likely have coverage for a broader range of preventive healthcare services than you would through another type of plan.  You may not be required to pay a deductible before coverage starts and your co-payments will likely be minimal.  With an HMO plan, keep in mind that you will  have no coverage for services rendered by a non-network provider or for services rendered without a proper referral from you PCP.

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How does a POS plan work?

A POS (Point of Service) plan combines some of the features offered by HMO and PPO plans.  As with an HMO, members of a POS plan are required to choose a primary care physician (PCP) from the plan's network of providers.  Services rendered by your PCP are typically not subject to a deductible.  Also, like HMOs, a POS plan typically offers coverage for preventative care visits. You may recieve a higher level of coverage for services rendered or referred by your PCP.  Services rendered by a non-network provider may be subject to a deductible and will likely be covered at a lower level.  If services are rendered outside of the network, you will likely have to pay up front and submit a claim to the insurance company yourself.

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How does an indemnity plan work?

A traditional Indemnity plan offers a great deal of freedom in choosing which doctors and hospitals to use, but will probably involve higher out-of-pocket costs and more paperwork.  Under an Indemnity plan, you may see whatever doctors or specialty you like, with no referrals required.  Though you may choose to get the majority of your basic care from a single doctor, your insurance company will not require you to choose a primary care physician.  An Indemnity plan may also require that you pay up front for services and then submit a claim to the insurance company yourself. You may have an annual deductible that will need to be met before the insurance company begins to pay on your claims.  Once your deductible has been met, the insurance company will typically pay your claims at a set percentage of the "usual and customary" (UCR) allowance for that services. The UCR rate is the amount that healthcare providers in your area typically charge for any given service.

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How does a HSA work?

Legislation establishing Health Savings Accounts (HSA) took effect on January 1, 2004.  HSAs and HSA eligible health insurance plans are becoming more and more popular.  Here are the basics:

  • A HSA is a tax-favored savings account that may be used in conjunction with a HSA-elgibile high deductible health insurance plan to pay for qualifying medical expenses.
  • Choosing an HSA-elgible plan may help you save money.  Typically, the monthly premium on an HSA-elgible high deductible plan is less expensive than the monthly premium for a lower deductible insurance plan.
  • Contributions to an HSA may be made pre-tax, up to a certain annual limit.
  • Funds in the HSA may be invested at your discretion.  unused funds remain in the account and accrue interest year-to-year, tax free.
  • Not all high-deductible plans are elgibile for use in conjunction with a HSA.

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What is a co-payment?

A "co-payment" or "co-pay" is a specific charge that your health insurance plan may require that you pay for a specific medical service or supply.  For example, your health insurance plan may require a $30 co-payment for an office visit or brand-name prescription drug, after which the insurance plan pays the remainder of the charges. For more information about co-payments, click here.

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What is a deductible?

A "deductible" is a specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims.  Not all health insurance plans require a deductible.  As a general rule, though there are may exceptions, HMO plans typically do not require a deductible, while most Indemnity and PPO plans do. To see more information about deductibles, click here.

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What is a coinsurance?

"Coinsurance" is a term used by health insurance companies to refer to the amount that you are required to pay for a medical claim, apart from any co-payments or deductible.  For example, if you health insurance plan has a 20% coinsurance requirement then a $100 medical bill would cost you $20.00 and the insurance company would pay the remaining $80.00.  

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What is the difference between in-network and out-of-network providers?

An in-network provider is one contracted with the health insurance company to provide services to plan members for specific pre-negotiated rates.  An out-of-network provider is one not contracted with the insurance plan.  Typically, if you visit a physician or other provider within the network, the amount you will be responsible for paying will be less than if you go to an out-of-network provider.  Though there are some exceptions, in many cases, the insurance company will either pay less or not pay anything for services you receive from out-of-network providers.

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Can I insure just my child(ren)?

When getting quotes for your child(ren) only, enter the child's gender and birth date in the "Applicant" or first row.  Additional children should be entered below that field in the "Child" rows, but not the "Spouse" field.  However, many health insurance companies require one policy per child.  So if you have more than one child, try entering just the one child to see a larger selection of plans and prices.  You are free to apply for each child separately.

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How does the Members Major Medical Plans system work?

It's simple and fast... members can shop, compare, and enroll in Major Medical insurance online or over the phone with a licensed representative.  We have a dedicated team of helpful, licensed insurance representatives who will not pressure you to buy. Our team is here to help you understand, compare, and strategize your options. Quote, Compare, Sort, and Apply.  The Members Major Medical Insurance Marketplace will shop top-rated carriers nationwide.  

Quote:  Insurance carriers include, but are not limited to:

  • Blue Cross Blue Shield (varies per state)
  • Aetna
  • United Health (Golden Rule)
  • Celtic
  • Kaiser
  • Additional regional and state insurance companies

Compare:  PPO, HMO, or Indemnity Plans available on the exchange include:

  • Health Savings Account (HSA) Qualified plans
  • High Deductible (Catastrophic Plans)
  • and more…

Sort:  The Member Major Medical Insurance Marketplace allows you to quickly sort plans by multiple variables, including:

  • Carrier
  • Deductible(s)
  • Price (lowest to highest)
  • Types of plans and more
  • Types of coverage (Prescription, Maternity)

Enroll:

You can enroll online or speak to a licensed insurance representative by phone.  It takes only minutes to enroll with most major insurance companies.

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