Sharing The Cost
Whether you choose a major medical plan, an HMO or a PPP, your plan will probably have some "cost-sharing" features. This means that you share the cost of care by paying part of the charge for each service and the insurance company pays the rest. Pick a plan that works best with the type of health insurance you think you will use. Different cost sharing features are listed below:
A copayment is a fixed dollar amount that you pay directly to a doctor, hospital or pharmacy at the time you get service. Example, you pay $20 for an office visit and the plan pays the rest. A Plan may have different copayments for different types of services.
The copayment for a primary care visit may be $20 and copayment for an emergency room visit may be $100.
A deductible is the amount you pay before the plan starts to pay for a covered service.
You pay a $1,000 deductible toward your health care services each year before the plan pays any Coinsurance is a percent of the allowed charge that you pay for a covered service.benefits.
Coinsurance is a percent of the allowed charge that you pay for a covered service.
You pay 20% of the cost of a covered office visit and the plan pays the rest.
Some health plans have a limit on the visits or dollars allowed for a specific covered service.
Example: The plan may allow only $350 for a wig and you will pay for any cost beyond the $350 limit.
Exclusions are listed services for which there is no benefit.
Example: The plan may exclude (not pay for) cosmetic surgery and you will pay for the entire cost of service.
An out-of-pocket maximum is a cap on your cost sharing for a year. Once your cost share amounts reach the out-of-pocket maximum, the plan pays 100% of the covered services for the rest of that year.
Ways To Get A Health Plan
There are many different ways that you can buy a health plan in Massachusetts. Many people get their health plan through their place of employment. For people that can't do this, there are several other ways to get a health plan.
Through Your Employer or Union
In Massachusetts over 70% of all employers offer health insurance as a benefit to their employees. Most of these employers pay part of the premium and also offer a choice of several health plans. You can choose the health plan that is best for you from the choices offered.
Qualified Student Health Insurance Plan (QSHIP)
If you are enrolled as a student in a Massachusetts college or university, you can buy a health plan through your school. This QSHIP id designed for students and is only available while you are enrolled. Keep in mind that you must have insurance if you are enrolled at least ¾ of the time in a Massachusetts college or university.
Directly from an Insurance Company
Massachusetts residents can buy health plans directly from an insurance company. And the company can't turn you down if you have a health condition. Sometimes the company will have you go through an intermediary. An intermediary is a company that takes care of the enrollment and premiums.
If you meet certain income requirements, you may be eligible for MassHealth. This is a Medicad program paid for by the state and federal taxes for eligible persons. You can learn more at http://www.mass.gov/eohhs/gov/departments/masshealth/or call 1-800-841-2900
Through the Connector
If you do not work for an employer that pays at least 33% of your health plan premium, you can buy a Commonwealth Choice health plan from the Connector. These are plans offered by Massachusetts HMOs that the Connector has picked to have good value.
If you are between the ages of 19 and 26, and are not eligible for subsidized coverage from your job, the Connector offers Young Adult Benefits Plans for Massachusetts residents. These are health plans designed for this age group.
If your family income isles than 300% of the federal poverty level, you may be able to buy a Commonwealth Care plan form Connector. Massachusetts helps pay for the Commonwealth Care premiums. This means that you pay a smaller premium or none at all, depending on your income.
If you are over 65, or if you have a certain type of disability, you may be eligible for Medicare. You can learn more by calling the Social Security Administration at 1-800-772-1213 or Visit your local Social Security Office.
Other Government Health Plans
The state and federal government provide lower cost health coverage for certain people through public health programs. This includes the Indian Health Services, Peace Corps, CommonHealth, HealthyStart and other programs. You may call 1-800-841-2900 to learn more about these programs.
Types Of Health Plans
Because there are many different types of health plans, you should be sure to look for the one that fits your needs. Here are some of the types of plans offered in Massachusetts:
Health Maintenance Organization
HMO plans cover hospital, medical and preventive care. You are only covered if you get your care from HMO's network of providers (except in a case of emergency). With most HMO plans you pay a copayment for each covered service. For example, you pay $10 for an office visit and the HMO pays the rest of the cost.
Preferred Provider Plans (PPP)
Preferred provider plans usually cover hospital, medical and preventive care. These plans have a network of preferred providers that you can use, but they also cover services for out-of-network providers. PPP's will pay more of the cost if you use a provider that is in the network. Example: the plan pays 100% of a service for a network provider but 80% for an out-of-network provider.
Major Medical Plans/ Indemnity Plans
Major medical plans usually cover hospital and medical expenses for an accident or illness. Some of them may also cover preventive care and office visits. These plans usually cover a percent of your covered costs. Example: the plan pays 80% of your hospital stay and you pay the other 20%. With these plans, you are covered for any licensed health providers.
Contact The Division Of Insurance
If you have questions about health insurance, contact the Division of Insurance by calling our consumer hotline - 617-521-7794 - or visit our website at www.mass.gov/doi.
Stop. Call. Confirm.
If you are unsure about the insurance company you are dealing with, STOP before signing any paperwork or writing a check; CALL your state insurance department - easily reached by phone; and CONFIRM the company or agent offering insurance is legitimate and licensed in the state.