Health Insurance Coverage for Individuals & Families

When you purchase a health insurance plan, you will pay a premium, which is a fixed monthly amount, much like you pay for car or life insurance. The premium is determined by the type of plan you have, as well as your age, your geographical location, and whether or not you use tobacco products. In addition, you may have to pay deductibles, copayments, or coinsurance amounts when you see your doctor or buy prescription drugs.

Generally, you will pay higher premiums for plans that include out-of-network benefits; plans that have low or no deductible, copayment, or coinsurance amounts; or both. You can choose to lower your monthly premium by purchasing a plan with a higher deductible. The type of plan you purchase should be determined by your anticipated health needs. For assistance in determining which type of plan would best meet your needs, please contact Growers Choice today!

Children with parents at or below 200 percent of the federal poverty level may be eligible for the Children’s Health Insurance Program (CHIP). If your child does not qualify for CHIP, then tax credits and cost-sharing reductions may be available at the Health Insurance Marketplace to make coverage affordable for your children. The cost of health insurance depends on how much coverage you choose to purchase and whether you qualify for state and federal programs that provide financial assistance. Many Virginians who have lower incomes will also benefit from lower costs in whatever plan they choose. The Kaiser cost-estimate calculator can help you estimate about how much you will pay per year for insurance coverage and the size of the financial support. These government financial assistance programs are offered on a sliding scale, based on your annual household income. In other words, the higher your income, the lower the amount of your financial assistance.

Determining how much you can spend on healthcare for you and your family is an important step to getting the right coverage.

Figure your known costs. Sort through your health-related expenses each year. Some key parts of your annual expenses will be health insurance premiums, dental exams, eye exams, prescription drugs, and medical doctor visits.

Ask your dentist, eye doctor, and medical doctor how often you should schedule check-ups. Based on your health insurance, you may have to pay for part of the visit fees and for any tests you have undergone. You will need to consider copayments, coinsurance, and deductibles. Add those amounts to your health insurance premium.

Include your medicine costs. Don’t forget to include the cost of any regular prescription drugs, over-the-counter drugs, and vitamins you take regularly. Check with your health plan to see what part of the prescription drug expense they pay.

Remember your family members’ costs, too. Repeat the last two steps above for everyone covered by your health plan.

Total your fixed costs. You now have an estimated annual total healthcare cost to assist in planning. You can divide the total by 12, and you will have an estimated monthly fixed cost of healthcare.

Save for the unexpected. You will have more challenges figuring out unplanned “surprise” costs. These expenses might include visits to the doctor for an illness or injury, medications to help with any illnesses, unplanned hospital stays or operations, and emergency room visits.

Your employer or health plan might offer ways to save for both your expected and unexpected healthcare costs.

If the reason for your change in affordability is due to a life-changing event such as the loss of a job, death of a spouse, or birth of a child, you would be eligible for special enrollment within 60 days of the event. If you do not enroll during this period, you will not be assured a health plan will cover you either through the Health Insurance Marketplace or in the private market. If you do not pay your premium, you could lose coverage and will not be able to enroll again until the next open enrollment period.

When you’re shopping for health insurance, you have a lot of options to choose from.

Knowing the differences between plans can help you choose the one that’s right for your health care needs and budget.

As you look at plans, you may notice that some plans are HMOs and some are PPOs, but what does that mean?

• HMO stands for health maintenance organization.
• PPO stands for preferred provider organization.

All these plans use a network of physicians, hospitals and other health care professionals to give you the highest quality care. The difference between them is the way you interact with those networks.

HMO Plans

You may cancel the policy/service agreement on the first of the month following our receipt of your written notice, unless otherwise stated. If you do not have other coverage, you may not be able to repurchase a plan before Open Enrollment for the next plan year begins, unless the change is due to a qualifying life event.

Medicare’s annual Open Enrollment Period is annually from October 15 to December 7.

Most people don’t have to pay a premium for Part A as long as they or their spouse paid Medicare taxes for at least 10 years while they were working.

There’s also no premium for Part A if:

• You’re receiving Social Security or Railroad Retirement Board (RRB) benefits at the time you enroll
• You’ve received disability benefits for at least 24 months.

There is a monthly premium for Part B, which is deducted from your Social Security or, for those who receive them, from their RRB benefits.

In addition to premiums, plan members are also responsible for paying a deductible and coinsurance with Original Medicare. After your deductible is met, you typically pay 20% of the Medicare-approved amount for most doctor services.

With Medicare Advantage options, instead of paying your healthcare bills directly, the federal government pays private insurance companies to administer your coverage.

While there is a monthly premium for Medicare Advantage options, many private insurance companies choose to offer affordable or $0 plan premiums to compete for your business. They also set the guidelines for your deductible, coinsurance and copays. To learn about Medicare Advantage options, contact Growers Choice today.

As with Original Medicare members, Medicare Advantage members must continue to pay their Part B premium.

There are 2 ways to get Medicare prescription drug coverage:

• You can choose a Medicare Advantage plan that includes prescription drug coverage (these are called Medicare Advantage prescription drug plans)
• You can purchase a stand-alone prescription drug plan—called Part D—to add to your Original Medicare

Your out-of-pocket costs for prescription drug deductibles, copays and coinsurance vary from plan to plan. Be sure to check each plan’s Drug List (list of covered drugs) to see what drugs are covered.

Yes, even with a preexisting condition, you can enroll in Original Medicare or a Medicare Advantage plan as long as you sign up for coverage during your initial enrollment period. This is the 7-month window that starts 3 months before your birth month and continues through the 3 months after your birth month in the year you turn 65.

With Original Medicare, a primary care doctor is not required. You can visit any doctor who accepts Medicare.

With a Medicare Advantage plan, your choice of doctor depends on whether you select a health maintenance organization (HMO) or preferred provider organization (PPO) plan.

With an HMO plan, you can choose your primary care physician from any doctor in the plan’s network. If you opt for a PPO plan, generally, choosing a primary care physician is optional. With both types of plans, you’ll usually save money by visiting a network provider.

It’s important to note that Medicare Advantage plans must offer emergency coverage outside of the plan’s service area, anywhere in the U.S.

Medicare is widely accepted across the United States, but it’s not universal. When reviewing plan options, pay close attention to which providers in your area accept Medicare to ensure that you have access to care when you need it.