Low premiums have to be balanced against out-of-pocket expenses that the plan does not cover. Becoming physical fit can improve their financial situation because it can reduce the need for medical treatment, and insurance companies know that.
Underwriting departments evaluate applicant’s medical history to determine whether to charge a higher than standard rate, to exclude coverage related to a pre-existing health condition or to refuse coverage completely.
The policy’s definition of out-of-pocket maximum may include or exclude certain out-of-pocket costs. To determine the worst-case scenario of all potential annual costs for health care, Tennesseans need to add the cost of excluded items to the annual out-of-pocket maximum.
For example, the annual out-of-pocket maximum may be defined as excluding costs such as the individual/family deductible, co-payments and pharmacy charges. A policy may also have conditional deductibles that need to be considered, like an extra $100 for going to the E.R. and not being admitted to the hospital.
Policies may also limit the number of mental health, rehab or substance abuse sessions that are covered per calendar year. If more than the pre-approved number of sessions is required, the cost of the extra sessions would need to be added to the annual out-of-pocket maximum.
In addition, there are often multiple levels of the annual out-of-pocket maximum, such as different amounts for an individual and the family as a whole, and different amounts for services from in-network and out-of-network providers.
For medical services that have an annual deductible requirement, a predetermined amount must be spent on health care before the plan covers certain expenses. The definitions in the policy determine whether more than one deductible applies.
For instance, a policy may declare that the individual/family deductible is satisfied when each family member has paid their individual deductible, or when the total family deductible amount has been reached by any combination of family members.
4) “Is the term co-insurance similar to the term co-payment?”
Both terms identify out-of-pocket costs, but the terms describe different expenses. Co-insurance is used to describe a percentage of coverage. It’s common for plans to pay 80 percent on covered medical services after the plan’s deductible has been met, but other percentages are also used. If a plan has 80 percent co-insurance, the policyholder is responsible for 20 percent of related bills after the deductible has been met.
Co-payment typically refers to a standard charge policyholders owe for items like doctor services or prescriptions. It’s common for policyholders to pay $25 or $30 for a doctor appointment, while the plan covers the remainder. Similar co-pays exist for filling prescriptions, and co-pay amounts vary depending on whether the prescription is for a generic drug, a brand-name drug or certain “non-preferred”
Tennesseans who improve their health by losing weight or quitting smoking can reduce the cost of their health insurance by up to 22 percent. In addition to lower premiums, their out-of-pocket costs for deductibles, co-insurance and co-payments fall as their health improves and they require less medical intervention. Understanding how policies define which services will be covered is key to getting coverage that’s adequate to protect financial assets. eTNHealthinsurance publishes more educational resources to help Tennesseans improve their health and their health care at http://eTNHealthinsurance.com/
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eTNHealthinsurance has become a leader in providing educational resources that enable Tennessee families, individuals and small businesses to keep their healthcare costs low. Online research of how to keep premiums low is available at http://www.eTNHealthinsurance.com/
eTNHealthinsurance also provides extensive tools to lower healthcare costs that are not covered by insurance at http://www.eTNHealthinsurance.com/
Tennessee small business owners, self-employed and residents seeking individual health insurance plans may use eTNHealthinsurance’