Group Health Plans
Offered by an employer as part of the benefits package.
- Employer pays a portion of the premium; employees cover the remainder.
- Bulk purchasing gives the employer a discount on the plan.
When you leave the job, COBRA lets you continue the same coverage, but you must pay both the employee and employer portions, making it much more expensive. Enrollment usually occurs after a probationary period and can be changed during open enrollment or after a qualifying life event e.g., marriage, birth/adoption.
Definition: COBRA – a federal law that allows former employees to extend their group health coverage for a limited time, paying the full premium themselves.
HMO vs. PPO common options within group plans
| Feature | HMO Health Maintenance Organization |
PPO Preferred Provider Organization |
|---|---|---|
| Monthly premium | Lower | Higher |
| Network restriction | Must use in-network doctors/hospitals except emergencies | Can use out-of-network providers (higher cost share) |
| Primary Care Physician (PCP) | Required; referrals needed for specialists | Not required; can see specialists directly |
| Flexibility | Less flexible | More flexible |
| Out-of-pocket cost | Generally lower for in-network care | May be higher, especially out-of-network |
- Marketplace Plans
- Sold through HealthCare.gov or state individual exchanges.
- Typically include HMO, EPO (Exclusive Provider Organization), and occasionally PPO options.
- Premium Tax Credit may lower monthly premiums if your MAGI (Modified Adjusted Gross Income) falls within eligible thresholds.
- Plans are categorized into metal tiers that indicate cost-sharing ratios, not the level of coverage.
Metal Tier Cost-Share Breakdown
| Metal Tier | Insurer Pays | You Pay |
|---|---|---|
| Bronze | 60% | 40% |
| Silver | 70% | 30% |
| Gold | 80% | 20% |
| Platinum | 90% | 10% |
- Bronze: lowest premiums, highest out-of-pocket.
- Platinum: highest premiums, lowest out-of-pocket.
Tip: Work with a broker who represents you rather than an agent who represents the insurer to find the best plan and eligibility for tax credits.
Private Health Insurance
- Purchased outside of the marketplace; no premium tax credits available.
- More likely to offer nationwide PPO networks for greater flexibility.
- Typically more expensive than marketplace options, but may be comparable if you don’t qualify for tax credits.
Agent vs. Broker
| Role | Works For | Typical Advantage |
|---|---|---|
| Agent | Specific insurance carrier | Direct access to that carrier’s products |
| Broker | You, the consumer | Can compare multiple carriers and find the best fit |
Short-Term Medical Insurance
Not available in every state; check local regulations.
- Designed for temporary coverage gaps e.g., between jobs.
Pros: Very low monthly premiums; ability to customize benefits.Cons:
- No coverage for pre-existing conditions first year.
- Excludes pregnancy and often pediatric care.
- Limited benefits compared to comprehensive plans.
Caution: If you have a pre-existing condition, you cannot be denied enrollment in a HealthCare.gov plan, making marketplace coverage a safer long-term option.
Medicare
Available automatically at age 65 or earlier with certain disabilities.
Consists of several parts:
| Part | Coverage | Typical Cost Share |
|---|---|---|
| Part A | Hospital inpatient services | Usually $0 premium if you or your spouse paid Medicare taxes |
| Part B | Outpatient, physician services, preventive care | Monthly premium income-based |
| Part C Medicare Advantage |
Private-plan alternative covering A+B; often includes vision, dental, prescription drugs | Varies by plan |
| Part D | Prescription drug coverage | Separate premium; varies by plan |
| Medicare Supplement (Medigap) | Covers gaps (deductibles, copayments) left by Original Medicare | Monthly premium depends on plan |
Enrollment tip: Begin researching at least six months before eligibility to compare Original Medicare, Medigap, Part D, and Advantage plans.
Healthcare Ministries
Definition: Healthcare ministries are member-driven groups that pool money to cover each other’s medical expenses without the structure of an insurance contract.
- No pre-negotiated rates or guaranteed reimbursement.
- Participants must negotiate fees and submit claims for reimbursement, which can be uncertain.
- Generally not recommended as a primary health-care financing method, though some find it works for their community.
Direct Primary Care (DPC)
- A membership model where you pay a low monthly fee for unlimited access to a single primary-care physician.
- Not insurance: does not cover specialist visits, hospitalizations, or surgeries.
Often combined with a high-deductible health plan (HDHP) or short-term medical insurance to protect against large medical expenses.
Key point: DPC provides affordable primary-care access but still requires some form of traditional insurance for comprehensive coverage.
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