Bleu Financial

Health Insurance

Health Insurance

Health coverage can be structured in very different ways. The first step is understanding what type of protection a policy actually provides.

Two different kinds of health coverage

Comprehensive coverage

Major medical coverage

Pays a share of your covered medical expenses, according to the plan's cost-sharing rules.

  • Covers the essential health benefit categories
  • Cannot refuse you or charge more for a pre-existing condition
  • Has a yearly limit on in-network cost sharing for covered essential health benefits

ACA-compliant coverage is sold two ways

  • Marketplace plans

    Bought through the Health Insurance Marketplace, which is the only place premium tax credits and cost-sharing reductions can be applied.

  • Off-Marketplace ACA-compliant plans

    Bought directly from an insurer or through an agent. Subject to the same coverage rules, without the Marketplace financial assistance.

These are different categories of product, not two grades of the same one. A limited-benefit policy is not a substitute for comprehensive coverage, and some people hold one alongside comprehensive coverage rather than instead of it.

Limited or supplemental coverage

Limited-benefit products

Pays set benefits according to the policy's own schedule or covered-event structure.

  • Pays set benefits defined by the policy
  • Benefits are paid regardless of what the care actually cost
  • Coverage, exclusions and limits are specific to each policy

Fixed indemnity is the most common example. Others exist, and what any of them covers depends on the individual policy — which is why the terms matter more here than the category name.

What each term actually is

Several of these words describe different kinds of thing — a category of coverage, a place to buy it, a way of paying benefits, a public program. Reading them as a list of competing products is what makes this section confusing.

  • A category of coverage

    Major medical coverage

    Comprehensive coverage that pays a share of your covered medical expenses under the plan's cost-sharing rules.

  • A rule set a plan meets

    ACA-compliant

    A plan meeting the Affordable Care Act's requirements — covering the essential health benefit categories, and unable to use a pre-existing condition against you.

  • Where coverage is bought

    The Marketplace

    The Health Insurance Marketplace, and the only route through which premium tax credits and cost-sharing reductions can be applied to a plan.

  • Where coverage is bought

    Off-Marketplace

    An ACA-compliant plan bought directly from an insurer or through an agent: the same coverage rules, without the Marketplace financial assistance.

  • A way of paying benefits

    Fixed indemnity

    A policy that pays set benefits for defined events regardless of what the care cost. CMS states it is not a substitute for comprehensive coverage.

  • A public program

    Medicaid

    A joint federal and state program administered by each state within federal rules, so eligibility and benefits vary by where you live.

Start with how coverage works if the vocabulary is new, or go straight to the Marketplace pages if you are choosing a plan. Reading the diagram above first makes the rest considerably shorter.

If you are approaching 65 or already eligible for Medicare, that is covered separately — the decisions, the deadlines and the rules there are different from everything here.

Understand coverage

How health coverage works

What every plan is read with: the costs, the network and the drug list.

How it worksYou pay to have coverage, and you share the cost of the care you use under the plan's rules — the rest of health insurance is detail on those two ideas.Costs and termsFive words describe almost every cost in a health plan. Each applies at a different moment, and the arithmetic only makes sense once they are kept apart.Provider networksA network is the set of providers a plan has contracted with. Whether a doctor is in it often matters more to your costs than the plan's premium.PrescriptionsEvery Marketplace plan covers prescription drugs, but each plan decides which drugs, and at what cost — which is set out in its formulary.

Marketplace and ACA

The Marketplace and its rules

Where ACA coverage is bought, when you can enroll, and how financial help and the metal levels work.

ACA / MarketplaceComprehensive major medical coverage sold through the Health Insurance Marketplace, under rules that apply to every ACA-compliant plan.Open EnrollmentThe yearly period when you can enroll in, renew or change a Marketplace plan without a qualifying life event. Outside it, one is generally needed.Special EnrollmentA window outside Open Enrollment to enroll in or change coverage, opened by a qualifying life event and usually lasting a limited time around it.Premium tax creditsA federal tax credit that can lower the cost of Marketplace coverage. Whether any applies depends on your circumstances, and advance payments are settled on your tax return.Metal levelsThe metal levels describe how a plan splits costs with you — premiums against costs when you get care — and nothing about the quality of care or the network.

Accounts and plan structure

Health savings accounts

How a health savings account pairs with a high-deductible plan.

HSA and HDHPAn HSA is a tax-advantaged account for medical costs, available to people covered by a qualifying high-deductible health plan and meeting a few other conditions.

Coverage types

Kinds of coverage

What each kind of coverage is, and the questions that establish which one you are being offered.

Private HealthA term that covers several different kinds of product — including comprehensive plans and policies that are not comprehensive at all.MedicaidA joint federal and state program, administered by each state within federal rules — so eligibility, benefits and even the program's name vary by where you live.

Want a second opinion before you decide?

Talk with a licensed insurance agent at Bleu Financial about the options in front of you. No pressure and no obligation.

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