Insurance for Families & Individuals

An HMO is: Health Maintenance Organization Plan
These plans provide IN Network benefits only (typically within the insureds service area of residency) and require that an In Network Primary Care Physician is assigned to the policy and one must obtain an In Network Specialist referral from the assigned PCP before seeing the Specialist.

An EPO is: Exclusive Provider Organization Plan
These plans provide IN Network benefits only (typically within the insureds service area of residency) and do not require a referral from an assigned Primary Care Physician on your policy to see an In Network Specialist.

A POS is: Point of Service Plan
This plan will provide In Network benefits and Out of Network Benefits. With this plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans also require you to get a referral from your primary care doctor in order to see a specialist.

Short-term Plan
A Major Medical Health plan that has a defined start date and end date. The policy cannot last longer than three months, with a possible extension of one month beginning September 2024.

Indemnity Plan
This type of plan does not replace major medical insurance. The coverage amount for services is predetermined for this type of plan, typically paying the policy holder a fixed cash benefit for covered services.

Any consumer earning a Premium Tax Credit to reduce their monthly health plan premium will reconcile the amount of the tax credit earned when they file their income taxes for the year that the credit was earned. The premium tax credit is based on an estimated annual income and has to be “trued up” once the income for the year is actually earned.

To reconcile, you compare two amounts: the premium tax credit you used in advance during the year; and the amount of tax credit you qualify for based on your final income.

In Network means that Providers and Facilities have contracted with Insurance Carriers and accepted the reimbursement rate for services that the Insurance companies are willing to pay Providers/Facilities. This typically results in about an 40%-60% discount on services to the Insured.

Out of Network are Providers or Facilities have no agreed contract with a Carrier and therefore the patient will pay the Provider or Facility for cost of Services at their requested price for services. Basically the patient will negotiate price directly with Provider or Facility for Out of Network services, becoming a cash pay patient. Some Providers will not accept cash pay patients or have insurance with a Carrier that they do not accept.

Emergency services are defined as a medical event that could cause loss of life or limb if not treated immediately, where ever the patient is regardless of their Insurance being Out of Network as in the case of the HMO or EPO.

Open enrollment is the time designated each year when you can purchase or apply for health insurance or make changes to your current health insurance plan, without a qualifying event. Different plans have different Open Enrollments.

• Individual Market is November 1st through January 15th annually.
• Medicare Annual Enrollment Period (AEP) is October 15th through December 7th annually.
• Medicare Advantage Open Enrollment Period is January 1 through March 31 annually.

Depending on the Clients situation and type of coverage they are needing, Special Enrollment periods are strictly defined and enforced. Certain situations allow for enrolling in a plan outside of Open Enrollment.