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Healthcare Insurance FAQ

Healthcare Insurance FAQ

The Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) or Obamacare, is the most significant regulatory overhaul of the U.S. healthcare system since the passage of Medicare and Medicaid in 1965.

Health insurance is a type of insurance coverage that covers the cost of an insured individual's medical and surgical expenses

Every health plan must cover the following services:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity, and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)

Health Insurance helps people meet their medical needs for affordable rates.  It also helps those who can’t afford health insurance get the protection they need.

Starting in 2014, the Affordable Care Act requires everyone to have health insurance or pay a penalty. Under the new law however, businesses with fewer than 50 full-time equivalent employees are not required to provide insurance to their employees.

The rates for each plan can be found here.


A deductible is usually a fix dollar amount that you have to pay out of your own pocket before the insurance will cover the remaining eligible expenses.Depending on the insurance plan, the deductible can range from $0 all the way up to thousands of dollars. It can also be paid per sickness/injury (per condition) or per certificate period. As a rule of thumb, the higher the deductible the lower the premium (price to buy the plan), and vice versa – but always be sure to choose the deductible that is appropriate for your circumstances when purchasing an insurance policy.


Coinsurance is usually a percentage, and represents the percentage cost that you will need to pay and the insurance plan will pay towards your eligible medical expenses. Some common coinsurance examples include: 100%, 80/20, 90/10 and 50/50 – so if you have 80/20 coinsurance on your insurance plan, it means that the insurance company will cover 80% of your medical cost and you are responsible for paying the other 20% yourself. A deductible is commonly use together with coinsurance. In this case you would pay the deductible amount first and after you would have the left over coinsurance amount.

Copay (copayment)

Copays are similar to deductibles, in that it is usually a fixed amount of money you have to pay each time you need to use your insurance plan. Unlike deductibles, copays tend to be smaller dollar amounts and are applied on a per visit basis so that that you would have to pay it each visit.

  • American Indians/Alaskan Natives
  • Prisoners
  • Most people already covered by a governmental program or by employer-sponsored coverage
  • People with really low income.
  • If insurance would cost you more than 8 percent of your income, you won’t have to buy
  • If you earn too little to file a tax return, you won’t have to buy
  • If you’re in a state where Medicaid wasn’t expanded and your income isn’t high enough to qualify for federal tax credits and subsidies, you won’t have to buy
  • Those who have had a gap in coverage for three months or less
  • People who have suffered a hardship
  • US Citizens who live outside the United States
  • Undocumented immigrants
  • Members of certain religious groups opposed to accepting benefits from a health insurance plan

Some provisions of the Affordable Care Act do not apply to so-called grandfathered plans written before the law took effect. These include the freedom to choose your own doctor, preventive services at no additional cost, and the right to appeal if your insurer denies a claim

Often 2 brand-name drugs help treat the same problem. Your insurance company may be able to get one less expensively than the other. That drug becomes a preferred drug, and the other becomes non-preferred. That's usually why you pay more for non-preferred drugs.