The Affordable Care Act (ACA) has made it easier for people without access to health insurance through their employers to purchase individual coverage. One of the main ways it has done this is the creation of the Health Insurance Marketplace. Where you can go to compare and shop for plans. These plans are much more standardized than plans were before the ACA, since they not only must now all cover the “10 essential health benefits,”. But they are also categorized into four “tiers” of coverage.
So, the first thing you should do if you’re in the market for individual health insurance is familiarize yourself with these tiers. Which are each named with a different metal type (Platinum, Gold, Silver, and Bronze). These different tiers do not indicate differences in quality of care. But in the percentages that you and your health insurance company will pay for your care.
In the sections that follow, we’ll break down the various health insurance metal tiers, as well as explain how to find out if you’re eligible for cost-sharing subsidies to help you choose the best plan for you and your family.
Health Insurance Plan Expenses
Before we get into the individual tiers, let’s take a look at the different expenses associated with all plans. There are five primary expenses you should be aware of, and they change from plan to plan. Make sure that you have accounted for these expenses in your plan’s budget.
In order to maintain insurance coverage, you’ll have to pay a monthly premium (or yearly premium if you prefer to pay in a lump sum). Premiums for plans will vary widely, but generally speaking, Bronze plans have the lowest premiums, followed by Silver plans, Gold plans, and Platinum plans.
Copays
A copay is a fixed amount that you will pay at the time of service for a medical service, or to see a doctor or specialist.
Deductible
Your policy’s deductible is the amount you’ll be responsible for paying before your insurance company begins covering any of your expenses. If your policy has a $1,500 deductible, for example, you will be responsible for paying that amount on covered care before your insurer begins paying for anything.
Bronze plans typically have the highest deductibles, meaning you’ll have to pay more out-of-pocket before your insurance kicks in. A Bronze plan’s deductible may be nearly twice as high as that of a Silver plan. Platinum plans typically have the lowest deductibles.
Coinsurance
Even after you’ve met your insurance plan’s deductible, you will most likely still have to pay a portion of your medical bills out-of-pocket, known as your coinsurance. A common coinsurance percentage is 20%, which means that once your deductible has been met (or until your out-of-pocket maximum has been reached), your insurance will cover 80% of your medical expenses, and you will pay the remainder. You can expect to pay the highest coinsurance for a Bronze plan.
The cost-sharing structure of the metal tiers is often misunderstood as coinsurance. Coinsurance is not the percentage that your Bronze plan covers (on average, 60% of consumer costs). All of your out-of-pocket costs (copays, deductible, and coinsurance) are included in the cost-sharing percentage of a metal tier.
Out-of-Pocket Maximum
While this isn’t technically an expense, it’s important to note that ACA-plans have what’s known as an out-of-pocket maximum. This means that once you pay a predetermined amount in healthcare expenses out-of-pocket, your insurance will begin to pay 100% of covered expenses. In 2023, the maximum out-of-pocket expense for an individual plan is $9,100, while the maximum for a family plan is $18,200.
The “Metal Tiers”
All plans sold on the Health Insurance Marketplace are placed into one of four coverage tiers established by the Affordable Care Act. You’ll most likely see these four categories referred to as “metal tiers” or “health coverage tiers.”
Don’t worry though, as we pointed out above, these metal tiers do not indicate differences in the quality of care you receive with these plans. These tiers only indicate how much of your healthcare costs you and your insurance company will be responsible for.
Plans were required by the ACA to begin classifying themselves in four actuarially determined categories: 60%, 70%, 80%, and 90%. This was done as part of the design process for the metal tiers and is meant to help you compare plans. Since these percentages indicate how much of your medical costs your insurance company will pay. Large group plans, such as those provided by an employer, are exempt from the tier requirements. But must have an actuarial value of at least 60%.
Remember, the cost of your plan always includes a number of factors. Like your monthly premiums, your annual deductible, copayments, and coinsurance. The metal tier you choose will dictate how much you pay for each of these. So let’s take a closer look at what this means for each metal tier.
Bronze
Bronze plans have the lowest monthly premiums of any plan type, but that doesn’t mean they are the cheapest plans. You will be responsible for a lot more of your care out-of-pocket if you have a Bronze plan. With these plans, your insurance company will cover 60% of your medical expenses. So, you will be responsible for the remaining 40%. Additionally, annual deductibles (the amount you are responsible for paying before your insurance plan kicks in to cover medical expenses) for these plans can be in the thousands.
So who are these plans aimed at? If you don’t anticipate frequent use of medical services, but still want to be covered in case of something like a serious illness or injury, a Bronze plan may be a good fit for your budget. But the high deductibles and coinsurance of these plans mean that you’ll have to pay a hefty chunk of your bill for even minor medical care out-of-pocket.
Silver
Silver plans are the most moderately priced plans. With these plans, your premiums will be a bit higher than those of Bronze plans. But you will pay 30% of the total cost of your medical care out-of-pocket, and your insurance company will cover the remaining 70%. In addition, the deductibles for Silver plans are lower than they are for Bronze plans.
So, if you’re willing to pay a little more for your premiums than you would with a Bronze plan, but want more of your routine medical expenses covered. Silver plans are a great choice because of their lower deductibles.
Gold
Gold plans have higher premiums than either Bronze or Silver plans do. But you will pay less out-of-pocket for medical services. If you have a Gold plan, your insurance company will pay for up to 80% of your medical expenses. Meaning you will only have to pay for the remaining 20%.
This is the best plan for you if you know you’ll be needing a lot of medical attention. Because it provides more comprehensive coverage, as well as lower deductibles. The higher monthly premiums will balance out, once you add up what you would have to pay for out-of-pocket with a lower tier plan.
Platinum
Platinum plans have the highest monthly premiums of any tier, but in exchange, they have the lowest deductibles and coinsurance. Your insurer will cover a whopping 90% of your medical bills with a Platinum plan. And you will only have to pay the remaining 10% out-of-pocket.
Just like with Gold plans, Platinum plans are a good option if you know you’ll be needing extensive medical care.
How Cost-Sharing Works
The term “cost sharing” is used to describe the splitting of healthcare expenses between you and your health insurance company. In fact, the name says it all. You share your medical costs with your insurer, like in the 30/70 split of a Silver plan. This means that you aren’t stuck paying for all of your medical bills on your own. But your insurer also expects that you cover a sometimes-significant portion of your care.
But, while the metal tier you choose will determine your cost-sharing percentage, your annual health care costs will be determined by the specific services you use and the specifics of your individual plan. For example, if you have a Bronze plan and you avoid all medical care for an entire year, only going in for an annual checkup. You will be responsible for less than 60% of your medical expenses for that year. However, if you get seriously ill and need surgery. You may end up paying for more than 60% of your care out-of-pocket.
How To Enroll
You can only enroll in an ACA metal tier plan during the period known as “Open Enrollment,”. Which begins on November 1 and ends on January 15 (in most states). During this time, you can also make changes to an existing plan. When you purchase a plan during the Open Enrollment Period, or OEP, your plan will go into effect on January 1 of the following calendar year.
Outside of the OEP, the only way to purchase or switch health plans is if you qualify for a Special Enrollment Period (SEP). You will need to experience a qualifying life event (QLE) in order to be eligible for one of these SEPs. QLEs include most significant transitions in your life, such as getting married, having a child, or changing careers.
EZ Can Help
Working with an EZ agent could mean saving hundreds of dollars on your premiums. Since we can search for plans both on and off the market for the best possible rates. Not only that, but we will also find any rebates for which you are eligible. And we won’t just help you find the best plan for you. We’ll also be here to support you after you make your purchase. For example, we’ll assist you in communicating with your insurance company regarding claims and policy renewals. To get started, simply enter your zip code in the box below. Or call one of our licensed agents at 877-670-3557.
There are a lot of moving parts involved in health insurance. As well as a lot of terminology to learn in order to understand your plan and its costs. Two of the most important terms to understand are premiums and deductibles. These are the two out-of-pocket expenses associated with your health insurance plan that will end up costing you the most money. Understanding these two terms, the difference between them, and how each operates will help you to better choose the best plan for your budget. Below we’ll explain how these two health insurance costs are interdependent and have an impact on each other.
Premiums
Like a Netflix or Spotify subscription, premiums are a monthly payment you make to maintain a service. In this case your health insurance plan. If you purchase an individual plan on the Health Insurance Marketplace, you will pay your premiums in their entirety. But you might be eligible for subsidies or tax rebates. If your employer offers a group health plan, the cost of your health insurance premiums may be partially or entirely covered by your employer.
How much you pay in premiums will vary based on several factors. Such as the policy you choose, the number of people in your family, and the insurance company you go through. In addition, when determining your premium, insurance companies may take into account factors such as your age, where you live, and whether or not you smoke cigarettes. For instance, because healthcare costs are assumed to increase with age, premiums for older adults are higher.
Premiums for individual health plans and family health plans function in the same way. There is only one payment required each month, so the cost itself is the only difference. The cost of your premium will be higher the more people who are covered by it. But, if you do the math, you might find that you’re paying less per person for a family plan than you would if you all had your own separate plans.
The only time this might not be the case is when someone in your family has significant health issues and another person rarely sees the doctor. In this case, it might be better to find plans that have lower premiums and higher deductibles for the healthier family member. And a plan with higher premiums and a lower deductible for the family member who needs more medical care. Let’s see why by taking a closer look at how deductibles work.
Deductibles
In most cases, your insurance plan will have an annual deductible. Which you will have to meet before your health insurance begins paying for any of your medical care costs. “Meeting” your deductible means that you will have to pay that amount in covered expenses to get coverage for anything other than preventive care. So, if your plan has a $2,000 deductible, for example, you’ll have to pay $2,000 out-of-pocket for things like lab work, minor surgeries, tests done at your doctor’s office, etc., and then your insurance plan will begin covering those things.
There are a variety of ways deductibles can work, and which medical expenses will count towards meeting them. Health insurance policies for individuals and families may include a deductible structure. In which the insurance company is not obligated to pay for services until the deductible has been met. But in some cases, a plan may cover some medical expenses before the deductible is met while excluding others. In addition, certain expenses like copayments won’t count towards your deductible.
Individual vs. Family Deductibles
Health insurance deductibles can either be applied per person or per family. The way individual deductibles work is fairly straightforward, while family deductibles can be a bit more complicated.
Individual – First, the easy part. If you have an individual health insurance policy, the money you spend on qualified medical expenses will count toward meeting your deductible. Once your plan’s deductible is met, you and your insurance company will begin dividing the remaining costs. Meaning you will pay what’s known as “coinsurance,” or a certain percentage of each bill. You’ll do this until you reach your policy’s out-of-pocket maximum.
Family – This is where things can get confusing, because your plan might have both an individual deductible and a family deductible. There are two main categories of family deductibles: embedded and aggregate. An aggregate deductible works the same as an individual deductible. Your plan will have one deductible, and everyone on the policy will be paying towards it.
Embedded deductibles, though, is where the confusion sometimes comes in. With an embedded deductible plan, there is both a family deductible and an individual deductible. So, each member of the family has a separate deductible in addition to the family’s deductible. Once a family member’s deductible is met, the insurance policy begins covering 100% of that person’s healthcare costs. Everyone else in the family will still have to meet their own deductible after that member’s deductible is met.
In addition, there is also a family deductible with these plans. And all family members will begin to have their expenses covered once the family deductible is met. Everyone will have to only pay their coinsurance until the out-of-pocket maximum is reached, once the family deductible is met.
Costs
The cost of your premiums and the amount of your deductible will depend on a variety of factors. It is difficult to give an accurate estimate of what you’ll pay without knowing your unique circumstances. Wut we can say that the average monthly premium price in the country is $456 per month.
Check out our state-by-state health insurance guides to learn more about how the health insurance market is regulated in your state. And to get a baseline estimate of the costs. You can also learn more about the health insurance plans that are available in your state. As well as ways to reduce the cost of your coverage.
As for deductibles, the average nationwide deductible amount depends on the metal tier you choose for your plan: Bronze, Silver, Gold, or Platinum. Keep in mind, lower deductibles mean a higher premium.
The average annual deductible amount for each tier is as follows:
Bronze – $7,482
Silver – $4,890
Gold – $1,650
Platinum – $745
How Premiums and Deductibles Work Together
Insurance premiums and deductibles are interrelated costs. Your plan’s premiums will be higher if the deductible is lower, for example. So, generally, your plan will either have a higher monthly premium with a lower deductible, or a lower premium with a higher deductible.
If you’re wondering which type of plan would be better for you. Consider that a higher premium with a lower deductible would be more appropriate for someone who has a pre-existing condition and needs to see the doctor frequently. And if you don’t often see the doctor or generally spend a lot on medical services, having a higher deductible won’t be as much of an issue for you. And you might be better off spending less on your premiums.
FAQs
How can I lower my premiums?
If you have individual coverage, and your household’s annual income is less than or equal to 400% of the federal poverty level, you might be eligible for subsidies or tax rebates. Which can lower the price of your premiums. If you have group health insurance through your employer, they might offer you reduced health insurance premiums or other incentives if you are able to meet certain health and wellness criteria.
What will increase my premiums?
Your health insurance premiums may increase for a variety of reasons. Including but not limited to inflation, adding family members to your plan, and relocating to an area with a higher cost of living. It’s also possible that your monthly health insurance premiums will go up if you opt for a plan with more generous benefits. Consider the policy’s premium in light of its benefits before making your decision.
Are premiums tax deductible?
If you have a plan through either the federal or state Health Insurance Marketplace, your premiums are tax deductible. If you’re self-employed, health insurance premiums are tax deductible. And you may also be able to deduct the premiums you pay for long-term care insurance. Before submitting a tax deduction claim, you may want to consult a tax expert.
Is a high or low deductible plan better for me?
If you do not anticipate having many medical expenses during the next plan year, selecting a health insurance policy that has a high deductible could give you the best value. When you anticipate having a lot of medical expenses in the near future, such as if you plan on having a baby, selecting a plan with a low deductible could help you get the most value out of your coverage.
What does “no-charge” deductible mean?
If you have a plan with a “no-charge” deductible, your plan will pay 100% of eligible medical expenses after you meet your deductible for the year. No-charge deductibles tend to be higher. But if you plan on using a lot of medical services for the year, it might balance out when you are no longer required to pay anything out-of-pocket.
How EZ Can Help
EZ.Insure provides access to local, highly trained insurance agents. Who will shop around for the best policy at the most affordable price. We can save you hundreds of dollars a year by searching both on and off the Marketplace for a plan that fits your needs. We can also find out if you’re eligible for any local discounts. And then apply them to your plan for you. And the best part is that we do all of this for free! To find out how much you could be saving, simply enter your zip code on the box below for free, instant quotes. Or call us at 877-670-3557 to speak to an agent who can answer all of your questions and find you the perfect plan.
Prescription drugs are not cheap. The good news is, though, that the Affordable Care Act requires insurance companies to cover them. But the bad news is that your insurance doesn’t always fully cover them. In fact, you may have to pay more than half the cost of some of your prescriptions out-of-pocket. So how do you know what drugs will be covered by your plan, and at what rate? To find out which drugs are covered and how much you’ll have to pay for them. You’ll need to familiarize yourself with what’s known as your plan’s drug formularies. This drug formulary is a list of medications that your plan covers. It also tells you how much of the cost of each drug it will cover. To find out what you need to know about your plan’s formulary in order to estimate your out-of-pocket prescription drug costs. Read our guide below.
Formulary Tiers
Each insurance company creates its own drug formularies. In fact, each plan offered by each insurance company may have a different drug formulary. So, it’s important to understand how they work and look at yours carefully. The most important things to look at are your formulary’s tiers. Since the tier that your medication is placed on will determine if you’ll be responsible for a copayment or coinsurance (both of which are explained below) when you fill your prescription.
Most formularies have four to six tiers that they use to classify medications. Drugs in the highest tier will cost you the most out-of-pocket. While those in the lowest tier will cost the least. Your health insurance company may have bargained with a drug manufacturer to secure a discount on some of these medications. In exchange, your health insurance will label the drug as a “preferred drug,”. Making it available to you at a reduced copayment.
The Tiers
Tier 1 – This is the lowest tier of medications. This tier consists of mostly generic medications.
Tier 2 – Tier 2 medications have a higher copayment than Tier 1 medications and may include preferred brand name drugs as well as non-preferred generics.
Tier 3 – This tier includes both preferred and non-preferred brand-name medications and has a higher copayment.
Tiers 4, 5, and 6 – Your most expensive medications are probably going to be in Tier 4, 5, or 6 of your plan, since it includes the most specialized types of drugs. Until you reach your plan’s annual out-of-pocket maximum for your healthcare plan, your out-of-pocket costs for drugs in the highest tier may be quite high. Because you will usually be required to pay coinsurance for them, rather than a copay.
In addition to a formulary of drugs that are covered by your plan. Your insurance company may also provide a list of medications that you will be responsible for the full retail price. These might include lifestyle drugs, such as those used to treat erectile dysfunction or obesity. As well as other prescription and over-the-counter medications. But with that being said, there is no universal drug formulary. So, some of these drugs may be covered by other health insurance plans.
If you’re choosing between two or more health insurance plans, it’s in your best interest to compare the drugs covered by each. This is true not only if you’re looking for health insurance through the Marketplace. But also if your insurance company offers multiple options for coverage.
What Are Copayments and Coinsurance?
You’ll see these terms a lot when looking through your health insurance plan options. A copayment (or copay) is the fixed dollar amount you are expected to pay toward the cost of a prescription. For example, your health insurance plan might cover Tier 1 drugs with a $20 copay per fill and Tier 2 drugs at $40 per fill, so you’ll be responsible for paying those amounts at the pharmacy counter. The rest of the cost will be covered by your insurance (after you’ve met any applicable deductibles).
If your drug requires coinsurance, on the other hand, that means you pay a percentage of the total cost of the medication rather than a flat copay (typical for drugs in Tier 4 and above, even if lower-tier drugs are covered with a copay).
For example, if your plan’s Tier 5 coinsurance is 30%, and the cost of the drug you need to fill it is $1,000 (after the discount your plan has negotiated with the pharmacy). You will be responsible for paying $300 out of pocket. Drugs for certain conditions, like multiple sclerosis (MS), are all specialty drugs. Meaning they fall into Tier 4 or higher and often require coinsurance.
Reviewing Your Plan’s Drug Formulary
You should always make sure to check out any plan’s drug formulary before making a decision, but it’s especially important if you have a condition that can only be treated with a specific medication. And no matter what prescriptions you think you’ll need, it’s important to shop around, since drugs may be placed on different tiers by different insurance companies. In addition, a drug that is in Tier 1 on one company’s plan may be in Tier 2 on another plan offered by the same insurer, while some insurance companies may not cover the medication at all.
Spending some time learning about formularies is time well-spent. Because it will help you choose a plan that works for you. You’ll also find out which drugs have different copays, limits on quantity, and which require you to pay your full deductible before they’re covered.
It’s clear that ignoring a plan’s drug formulary can lead to money wasted. You’ll be in a better position to choose the right plan for your needs if you take the time to familiarize yourself with your formulary’s tiers.
Drug Formulary Restrictions
Most health plan formularies include procedures for limiting or restricting the use of specific medications. This is done to encourage your healthcare provider to use specific medications correctly, as well as to save money by avoiding medication overuse.
Some common restrictions are as follows:
Prior Authorizations – Your healthcare provider may have to obtain approval from your insurance company in order for a medication on your plan’s formulary to be covered. Typically, prior authorizations will be required for medications that may pose a safety risk, have a high risk of inappropriate use. Or have lower-cost alternatives on the formulary.
Quality Care Dosing – Your pharmacist might have to inspect medications your doctor prescribes you before you fill them to make sure that the quantity and dosage are in accordance with FDA recommendations. If the prescription doesn’t meet FDA requirements, your insurer can refuse to cover the medication.
Step Therapy – You might have to first try one medication to treat your health condition before moving on to another. The first medication is usually the less expensive option.
Exceptions
Your healthcare provider might have access to your health plan’s formulary, but they might not. So, there is a chance they might prescribe you a drug that is not covered by your plan. But if you do find that a drug you need is not on your plan’s formulary, your doctor can submit an “exceptions process” form. This lets your insurance company know that the medication they prescribed to you is medically necessary.
There are other cases in which your health insurance company might be flexible enough to allow for a few exceptions. In addition to requesting that your plan pay for a drug that is not on its formulary. You can also request that your plan continue to pay for a drug that is being taken off your plan’s formulary. You can also request that your plan’s limitations on your medication coverage be lifted. Or that your insurer lower the copayment for the medication.
If your health insurance does not cover your medication and doing so would result in you using a less effective drug or experiencing a harmful medical event, you may be eligible for one of these exceptions. And, if your request for an exception is denied, you have the option to file an appeal. The Affordable Care Act mandates that all health insurance companies offer appeals procedures. And these procedures must be accessible to all members of the public. You still have the option of having your doctor prescribe the medication if your appeal is denied. But you will be responsible for paying the full cost of the medication.
Steps To Take
If you’re in need of prescription medications, and want to make sure they’re going to be affordable for you, you’ll have to follow a few steps:
Know your plan’s formulary.
As noted, you should always familiarize yourself with your health insurance plan’s formulary. This is because formularies can vary widely from plan to plan. You can ask about each plan’s formulary when shopping for a plan, and you will receive details about the formulary and a list of all approved medications. As well as an explanation of the tier co-payments and/or coinsurance, when you sign up for coverage. Your plan’s formulary is also available online for your convenience. Call the customer service number listed on your drug card if you haven’t received a formulary. Or if you can’t find it online.
Speak with your healthcare provider.
If you’re in need of medication prescribed by a doctor, discuss the possibility of receiving a generic version of the drug. Make sure your doctor is familiar with your health insurance’s formulary. So, that if a more expensive medication is required, one that is covered by your policy can be prescribed.
Choose your plan wisely.
Look at the formularies of multiple health plans. So, you can determine which one will cover the medications you need to treat your condition. You may find that no health plan covers everything you need. But you can certainly find the one that is best for you. Speak to an EZ agent about which plan has a formulary that will cover as many of your prescription needs as possible.
If you can’t find a plan that covers everything, let us help you find the health plan that covers your most expensive medications. Keeping in mind that you may have to pay full price for the less expensive ones as a result. Again, this is a situation in which you and your doctor can discuss the possibility of switching to a different drug from the same class that is available on the formulary.
Working With EZ
If you need assistance, EZ.Insure is here to provide it. Our team of experts can quickly and accurately compare all available health insurance options in your area. A dedicated representative will be assigned to you to explain all of your options, how they cover prescription drugs, and then assist you in selecting a plan. And the best part is that we do it all for free! Enter your zip code in the box below to get your free quotes. Or give us a call at 877-670-3557 to talk to an agent.
Finding one insurance plan that’s right for you can seem like a big task. But in some cases, you might actually be wondering if it’s possible to have two health insurance plans. And the answer is yes: it is possible and legal to have two policies, a primary and secondary health insurance policy. And while it might seem like a lot of extra work to research and maintain two plans, having two different health insurance plans can actually help you save money on the overall cost of your medical care and treatment.
With that being said, having two plans can also mean paying twice as much each month for your premiums. As well as twice as much for your deductible. So if you are considering purchasing additional coverage, you’ll need to give serious thought to whether or not enrolling in a second health insurance plan would be the best option for you.
To help you make this decision, we’ve broken down how primary and secondary insurance policies work. So you can understand the difference and get a better idea of how two policies could work for you. And, as always, if you have any questions, or need help looking for the right policy – or policies – for you, contact an EZ agent!
Primary Insurance
Your primary plan will be the plan that will first cover any necessary medical care. This plan will pay before your secondary insurance plan kicks in. For instance, if you need to see a doctor or buy prescription drugs, your primary insurer will cover the costs of these services up to the coverage limits that it provides. Remember, though, as with any health insurance plan, you may still be responsible for cost-sharing, like coinsurance.
Secondary Insurance
In most cases, if you have a secondary insurance plan, it won’t begin to pay out benefits until after your primary insurance plan has exhausted its available coverage. After your primary insurer has paid its share of your medical costs, your secondary plan will begin to take effect to cover any additional costs that remain.
How to Get Two Plans
Getting secondary health insurance is similar to getting primary health insurance, but there are some differences to keep in mind. Here are the steps to getting a second policy:
Assess your primary policy – Review the policy documents for your current plan to find out what services are covered, how cost-sharing works, and what coverage limits there are. Think about your current and future health needs to find any gaps in your coverage.
Research secondary options – Options for secondary coverage range from plans that cover just one type of health service to plans that cover everything. Find out what kinds of plans are available to you and choose the one that fills in the gaps in your current coverage the best.
Understanding coordination of benefits – People can’t choose which of their two health plans is the “secondary” one. Before you sign up for another plan, make sure it will pay after the one you already have.
Apply and purchase – To sign up, follow the instructions for the plan you’ve chosen. Fill out the forms carefully and be ready to answer questions about your current health insurance. Pay your first month’s premium after getting approved for coverage.
How Does Having Two Plans Work?
When you have a medical bill, the first insurance that pays out is your primary insurance. It will pay up to its coverage limits. Then your secondary insurance will kick in and can pay part or all of the remaining costs. Please be aware that there are limits to the coverage provided by both the primary and secondary insurance. If the secondary insurer does not pay in full, the remaining balance will be your responsibility. Therefore, it is possible that you will have some remaining out-of-pocket medical costs. Even if you carry multiple health insurance policies.
There is a good chance that a Coordination of Benefits clause is included in your health insurance policy. This clause will lay out the predetermined order of how your plans will pay for your covered services. So, in the event that you or your medical provider file a claim for your care, the Coordination of Benefits document will specify which plan is accountable for making payments.
Examples of Primary and Secondary Plans
So, if you have more than one insurance policy, which policy is considered primary and which is considered secondary will be determined by your circumstances. The following are some examples of how primary and secondary plans work for different groups of people:
Married Couples – Say a wife has her own insurance but she is also covered under her husband’s group insurance from his job. The wife’s primary insurance would be her individual plan and her husband’s group coverage would be the secondary.
Minors under 26 – Under the Affordable Care Act, dependents can remain on their parents’ insurance until age 26. This means that an adult under this age could get their own health insurance policy from their employer while still being covered by the family policy. If that’s the case, the child’s health insurance would be the primary plan. And the parent’s would be the secondary plan.
Parents with separate plans – Say you are under 26 and still on your parent’s health plan. If they both have separate plans and you’re listed on both of them, you have dual coverage. The primary and secondary coverages are determined by a “birthday rule”. Meaning whichever parent’s birthday is earlier in the year will give you your primary insurance. And the one with the later birthday will give you your secondary plan. For example, if your mom’s birthday is in January and your dad’s birthday is in March. Your Mom’s insurance would be your primary coverage. This isn’t about which parent is older – the birth year doesn’t affect the order, only the birth month.
Medicare beneficiaries with group health plans – If you are 65 or older and on Medicare, but are still working and have insurance through your employer, Medicare will be your primary insurance if the company you work for has fewer than 20 employees. If your company has 20 or more employees, your group plan will be primary and Medicare will be secondary.
Out-Of-Pocket Costs
The cost of having two plans will generally be higher than the cost of having one plan. Since you will have to pay the premiums and deductibles for each of your health insurance policies. For example, consider this: you will not be able to use your secondary coverage to cover your primary’s deductible. You will also have to pay any copayments and coinsurance that are associated with each plan.
It’s also important to note that the rules of your primary plan will apply to both of your policies. So, for example, if your primary plan is a PPO plan. Your primary policy may stipulate that you can only use certain doctors and hospitals in your plan’s network. Your primary insurance won’t pay anything if you go to a doctor who isn’t in their network. The secondary insurance won’t either because you broke the primary plan’s rules by going to an out-of-network doctor.
In addition, if your provider charges you more than what your plan(s) considers to be reasonable, customary, or allowed under plan rules, you may have to pay the difference. A licensed insurance agent from EZ can help you understand the out-of-pocket costs associated with each of your plan options.
Weighing Your Options
There are positives and negatives associated with choosing to have a primary and secondary insurance plan. Just as there are with any other type of insurance. Let’s take a look at the pros and cons to help you decide if having two plans might be right for you.
Benefits
Extra Coverage – Having two plans could come in handy in the case of unanticipated medical expenses. And if you find that you frequently have to pay for your own medical expenses out-of-pocket, it may be beneficial to purchase a secondary health insurance policy.
No Gaps – Even if one of your health insurance policies lapses, you won’t experience a gap in coverage if you have a second plan. Your secondary health insurance will just become your primary automatically.
Complementary coverage – Having plans that are complementary, that cover different elements of your healthcare, will mean you’ll get more coverage and better benefits. You’ll be able to make up for what your primary health insurance doesn’t cover with your secondary plan.
Disadvantages
No guarantee – Even if you have two separate health insurance policies, your out-of-pocket costs may still not be covered in full. Keep in mind that the amount of your plans’ coverage cannot be more than the amount of your out-of-pocket expenses.
Extra expenses – Your two separate health insurance policies will still require you to make payments on the associated premiums and deductibles. This may result in additional expenses further down the road.
Overlapping – It’s possible that your coverage from two different health insurance plans will actually overlap if the plans are too similar to one another. Meaning you will not receive as many additional benefits as you might like.
FAQs
What is the birthday rule?
When children are covered by both parents’ health insurance policies, the birthday rule plays a significant role in determining which plan provides primary coverage and which provides secondary coverage. According to the birthday rule, whichever parent’s birthday falls earlier in the year will be the primary insurer. Secondary insurance is provided by the other parent’s plan. The year of birth of each parent does not come into play.
How do I know which is my primary insurance?
You don’t get to choose which plan will be your primary coverage and which will be your secondary coverage. Whenever you file a claim, your primary health plan will cover you as if you didn’t have a secondary plan. After that, your secondary health insurance will cover the rest of the bill. If you have two health plans, there are rules about how your benefits will work together. Some of these rules will be different for you based on your health insurance company and your situation.
Is having 2 plans worth it?
It depends. Having two health plans can save you money if one is free or both are inexpensive. Also, it’s best to make sure they work well together. Check to see if their coverages and benefits overlap or are too similar.
EZ Is Here to Help
Having both primary and secondary coverage can be complicated. It could work for you, but you’ll need to weigh the pros and cons carefully before deciding whether or not to invest in a secondary insurance policy. Feel free to ask EZ anything. Including if having two plans might be right for you, as well as for assistance in locating a secondary health insurance plan, if necessary. We will compare plan benefits and costs for you. And will assist you in locating affordable coverage that meets your needs. Simply enter your ZIP code below to get started with free, customized quotes right now! You can also give us a call at 877-670-3557 to have a qualified insurance professional discuss your needs and help you choose the best policy for you.
National Eating Disorders Awareness Week is from February 23rd to March 1st, and we feel it’s essential that we shed light on this important topic. After all, according to the National Eating Disorders Association (NEDA), 30 million Americans struggle with eating disorders, such as anorexia, bulimia, and binge eating. This is an overwhelming amount of people that are living with eating disorders, especially considering the impact that these conditions have on people’s lives, and on the fact that they can even be fatal.
If you or a loved one are struggling with an eating disorder, you need to know how you can get help, and if your insurance will cover your treatment. So, you should know that most insurance plans will cover some form of treatment, but how much they cover will be dependent on your plan.
Eating disorders affect a person’s relationship with food and body image. People who are living with an eating disorder tend to be hyper-focused on the food they eat, their body weight or shape, and/or how they control their intake of food.
Different types of eating disorders include:
Anorexia nervosa, whichis characterized by weight loss or maintenance through extreme dieting, starvation, or too much exercise.
Binge eating, which means frequently consuming an unhealthily large amount of food in one sitting.
Bulimia nervosa, which can involve purging (throwing up), taking laxatives, exercising, or fasting to avoid weight gain after binge eating.
Eating Disorder by the Numbers
As stated above, eating disorders are by no means minor problems. Consider the following:
Eating disorders are the third most common chronic illness among adolescent females in the United States.
A quarter of people with anorexia are male. Men have an increased risk of dying from eating disorders, because it often takes much longer to diagnose them than it does women.
The median age of eating disorder onset is 21 for binge eating disorder and 18 for anorexia and bulimia nervosa.
Roughly one person dies every hour as a direct result of an eating disorder.
Insurance Coverage for Eating Disorders
As we mentioned above, your health insurance should cover treatment for an eating disorder. But your insurer’s coverage might not be the same as another person’s. Coverage for treatment depends on your plan, the state you live in, and the severity of your disorder.
If you are considering seeking treatment for an eating disorder, it is important to ask the following questions of your insurance company:
Will coverage be applied for both inpatient and outpatient care?
Is nutritional counseling covered?
How long will my treatment be covered for, and how many trips to rehab are covered during a policy year?
Which providers are covered?
It is also important to think about your personal needs. For example, anorexia often warrants inpatient or partially hospitalized care. So treatment professionals can make sure you’re eating a balanced diet. Generally, health insurance companies will cover at least 10 days of inpatient rehab for eating disorders, where you can work on your mental health, and receive nutrition counseling to help foster a healthy approach to eating and food.
It is important to note that if you have a substance abuse problem accompanied by an eating disorder, some insurers will only make payments toward outpatient care when substance abuse is the primary issue.
Is Your Plan Sufficient?
One of the most important factors in getting the help you need for an eating disorder is your health insurance. Before purchasing a plan, make sure you understand what coverage it offers. And make sure it will cover evaluation and treatment.
If you’re not sure what plan is right for you, speak to an EZ agent! EZ agents are highly trained and knowledgeable and will sort through all available plans to make sure that treatments for eating disorders are covered in yours.
We offer a wide range of health insurance plans from top-rated insurance companies in every state. And because we work with so many companies we can can show you all of the plans available in your area. And we can find you a plan that saves you hundreds of dollars. Even if you don’t qualify for a subsidy. There is no obligation, or hassle, just free quotes on all available plans in your area. To get free instant quotes, simply enter your zip code in the bar above, or to speak to a local agent, call 888-350-1890.
Turning 65 can feel like hitting a milestone. At this point in your life, you’ve lived a long life and made a lot of memories and are looking forward to making more! And one of the best ways to keep going strong is to have a good insurance plan that will protect your health. Fortunately, turning 65 also means you can finally benefit from Medicare, which you’ve been paying into your whole working life, so you will have some pretty good coverage to help you do this. But Medicare alone is not enough. You’ll also need something, like a Medicare Supplement Plan, to fill the gaps in your coverage.
You might be seeing a lot of commercials about different Medicare plans available to adults 65 and older to help you fill those gaps. And it can all be confusing as to what direction you should go, but this is where EZ can help you. We will go over everything you need to know and provide you with quotes for all the plans in your area at no cost to you, so you can get fully covered and get back to living your life!
So why do you need an insurance plan if you already have Medicare? Well, while Medicare Part B covers outpatient medical services, including durable medical equipment, there are quite a few out-of-pocket expenses associated with it. You will have to pay a monthly premium and meet your annual deductible, as well as cover your 20% coinsurance for each service you receive, since Part B only covers 80% of costs.
To fill these gaps in Part B, you’ll need a Medicare Supplement Plan. For one low monthly premium payment, Medicare Supplement Plans cover things like deductibles, copays, and coinsurance, and can even offer extras like coverage for when you’re traveling.
Save Time
There are around 10 Medicare Supplement Plans available, meaning you have a lot of options. But it also means that looking into all the various plans available, and what each plan entails, while trying to figure out if these plans will suit your specific needs, can be very overwhelming. Working with one of our agents will save you the time and frustration of searching through all the different plans available in your area.
We will also save you time by sitting down with you and discussing your medical needs and your budget, to find only the plans that will work for you. We’ll show you which plans cover your current providers, and any other necessities you would like, such as travel insurance. Then we will go through all available options with you and explain each one so that you get a full understanding of the coverage options and the costs.
Finally, we will save you time by helping you enroll in the plan in a matter of minutes when you are ready.
One of the most nerve-wracking things is trying to find a plan that keeps your prescriptions affordable. It is no secret that many Americans, especially seniors, struggle to pay for medications, but working with an EZ agent will allow you to see all of your options for prescriptions coverage and save the most money.
If you’re retired and living on a fixed income, you’ll need to budget carefully for your daily expenses, and you’ll need a plan that fits into that budget. We can help you find a plan that will do just that, giving you the ability to save money for other things that matter in your life, such as traveling or your grandchildren.
No Need to Look Further
As we pointed out above, if you’re a Medicare beneficiary and need help paying for the things that Medicare doesn’t cover, you have the option of purchasing a Medicare Supplement Plan. Your plan can help pay for the things that Medicare does not, including the 20% coinsurance that you will have to pay out-of-pocket for every Part B-covered service. One of these plans could cover 100% of your Part A coinsurance and hospital costs, as well as 100% of Part B coinsurance and copayments, for one low monthly premium price.
There are 10 different Medicare Supplement Plans to choose from, each offering different coverage options and rates. It’s worth looking into a Medicare Supplement Plan to save as much money as you can, so speak to an EZ agent for all of your options. EZ’s agents work with the top-rated insurance companies in the nation and can compare plans in minutes for you at no cost. To get free instant quotes for plans that cover your current doctors, simply enter your zip code in the bar on the side, or to speak to a licensed agent, call 888-753-7207.
