What You Need to Know About Health Insurance

Many employers provide health insurance to employees and their families. In fact, this is the most common way people get coverage, and it may be a more convenient and affordable option for families.

Employer-based health insurance (also known as group health insurance) is a type of health coverage a company may offer to the people who work there.

When employers provide health coverage, they may:

• Offer insurance coverage to eligible employees.
• Pay part of the employee’s monthly premium.
• Cover the employee’s dependents or family members, depending on the plan.

Enrolling in a health insurance plan through your employer may be a great option. Although you will likely still have to pay a monthly premium, it is usually more affordable than purchasing an individual plan.

How do I sign up for employer-based health insurance?

When applying for or starting a new job, ask the employer about your benefits to see if you can get health insurance coverage for yourself and your family through them. Once you begin your employment, it may be a month or more before your coverage begins (also known as a probationary period).

If you can receive health insurance through your employer, you will have to sign up again each year during the company’s open enrollment period or following a life event (including childbirth, marriage and more).

What is TRICARE?

If you or a family member are in the military (or otherwise eligible), your family’s coverage may be through TRICARE. Although this is similar to employer-based health insurance, TRICARE does have some very specific rules.

For those who qualify, there are three different ways to receive government-assisted coverage. You may be eligible for one of these programs depending on your income, age, health condition and other factors.

What is Medicaid and how do I sign up?

Medicaid provides coverage for low-income individuals who meet specific eligibility criteria. Coverage will look different across states, but there are some services that every state must cover.

Every state in the U.S. is required to cover these health services under Medicaid*:

• Inpatient hospital services
• Outpatient hospital services
• Physician services
• Laboratory and X-ray services
• Home health services

Eligibility requirements are different across states. Visit the Georgia Medicaid website to see if you are eligible in the state of Georgia.

What is Georgia Pathways to Coverage^TM?

Georgia Pathways to Coverage^TM is a Medicaid program designed to extend Medicaid coverage to low-income adults who don’t qualify for traditional Medicaid. To be eligible you must work, attend school, volunteer or complete another qualifying activity for at least 80 hours per month.

What is the Children’s Health Insurance Program (CHIP)?

The Children’s Health Insurance Program (CHIP) is a government program that provides health coverage to uninsured kids. It is for families with incomes too high to qualify for Medicaid, but too low to afford an individual plan. In Georgia, this is offered through PeachCare for Kids®.

Every state in the U.S. is required to cover these health services under CHIP:

• Doctor visits
• Immunizations
• Prescriptions
• Dental care
• Vision care
• Hospital care
• Laboratory and X-ray services
• Emergency services
• Behavioral health services

Like Medicaid, each state has different rules about who qualifies for CHIP. Visit the PeachCare for Kids® website to find out if your child is eligible.

What is Medicare and how do I sign up?

Medicare is a federal health insurance program for those aged 65 and older, or children with end-stage renal disease. Medicare does not provide plans for families, only individuals, and eligible recipients can choose how they want to receive their Medicare coverage based on their needs and budget. Costs and coverage can change, so it’s important to review and compare different plans each year.

Visit Medicare.gov to see if you are eligible for Medicare. If you're able to receive Social Security benefits when you turn 65, you will automatically be enrolled in Part A and Part B.

Individual health insurance coverage is available for individuals and families who do not qualify for or choose not to purchase insurance through the government or an employer. Some people who might consider purchasing an individual healthcare plan include:

• People who work part-time, work as contractors, or work for a company that does not offer healthcare.
• Self-employed people.
• People who need to fill a gap in coverage.

What is the Marketplace?

The Marketplace is a platform that helps people compare health insurance plans and costs. In Georgia, residents can enroll in health coverage through the state Marketplace, Georgia Access.

How can I buy private health insurance?

If you don’t qualify for employer-based health insurance or government-funded health insurance, you can buy your own plan. Here are some options for buying a private plan:

• Directly from a health insurance company: Contact a health insurance company, such as Aetna or Cigna, or visit its website to compare the plans it offers.
• Through an insurance agent or broker: An agent or broker can help you find the best plan for yourself and your family based on your needs. It is usually a free service to use.
• From an online seller: Online health insurance sellers can help you compare plans and buy from different insurance companies.

An HMO plan requires you to manage care through a primary care provider (PCP). This doctor will need to make referrals for specialized services, such as those provided by a surgeon. The network for these plans may be limited. If you travel outside your area to receive care, you may have to pay an out-of-pocket cost.

While an HMO plan typically has lower premiums and out-of-pocket costs, the network of available providers is usually much smaller with an HMO.

Benefits of an HMO plan

• Lower premiums than many POS or PPO plans
• If you stay in network, out-of-pocket costs can be more budget friendly than POS or PPO plans

Disadvantages of an HMO plan

• Typically less flexibility than POS or PPO plans
• All health services go through your primary care provider
• Usually a narrower network than POS or PPO plans
• No out-of-network coverage (except in emergencies)

A POS plan typically has a larger network than an HMO plan, but you are still encouraged to get care from in-network providers. Referrals may be required for in-network specialists, but you can still see out-of-network providers at a higher cost.

While a POS plan usually provides more flexibility than an HMO plan, it costs more on a monthly basis, and you will still need to rely on your primary care physician for in-network referrals to keep costs lower.

Benefits of a POS plan

• Often larger network than HMO plans
• Can receive out-of-network coverage
• Often can seek additional care without a referral

• Usually higher premiums than HMO plans
• Out-of-network services can be expensive
• Usually a smaller network than PPO plans

A PPO plan typically has the largest network of providers and likely the highest premiums and out-of-pocket costs. You usually will have more flexibility when choosing care and don’t need a referral to see a specialist. You can often get care from out-of-network providers, but it may be more expensive.

While a PPO plan typically has higher premiums and out-of-pocket costs, it usually offers the most options when choosing providers.

Benefits of a PPO plan

• Usually largest network of providers compared to HMO and POS plans
• Flexibility when choosing care
• Often lower copays and co-insurance for in-network providers compared to POS plans
• Can receive out-of-network coverage
• Can seek additional care without a referral

Disadvantages of a PPO plan

• Higher premiums than HMO or POS plans
• Out-of-network services can be expensive

We know understanding insurance benefits and coverage can be confusing and even overwhelming. Here are some common insurance terms and definitions to help you get started.

C

Carve out
An insurance plan may carve out specific services or providers by not including them in your coverage. Instead, your plan may include them in another plan or network. For example, mental health services may be managed by a different plan or network.

Claim
You or your provider can submit a claim to your insurance company to ask it to pay for a doctor’s visit or treatment you had.

Co-insurance
Co-insurance is a percentage of the cost that you will have to pay before or at the time you receive care. Your co-insurance will begin to apply after you have paid your deductible.

For example, if your co-insurance is 20%, after you have paid your deductible, you will pay 20% of the cost and your insurance will pay 80%.

Copayment (or copay)
A fixed dollar amount paid before or at the time you receive care. For example, you may have a $20 copay to see a primary care doctor or a $30 copay to see a specialist.

D

Deductible
The amount you must pay before the insurance company begins paying your medical bills. Some plans may have both an individual and family deductible and out-of-pocket max. There are also plans with a separate deductible for pharmacy services.

For example, if you have a $1,000 deductible, you will pay the first $1,000 of covered services. After you pay your deductible, you will only have to pay copayments and co-insurance for covered services.

Dependent
Anyone, such as a spouse or child, who is covered by your plan.

Deposit/Pre-service payment
You may be asked to pay a deposit toward your expected cost of service. Your provider might ask that you pay a deposit before or at the time you receive care.

F

Formulary
A list of prescription drugs that your insurance will cover, and you will receive from a pharmacy.

G

Group number
An ID number that can be found on your insurance card. For example, people who receive insurance through the same employer might have the same group number.

I

In-network or in network
Healthcare professionals, hospitals or pharmacies that are covered by your health insurance plan. They offer services at a discounted rate. You will generally pay the least for in-network providers.

Insurance card
Your ID card that shows proof of your health insurance coverage. You may be asked to share your insurance card before receiving care.

M

Marketplace
A platform that helps people compare health insurance plans and costs, created as a part of the Affordable Care Act. Georgia residents can enroll in health coverage through the state Marketplace, Georgia Access.

N

Narrow network
A narrow network plan places limits on the providers your insurance covers. For example, the plan may only include a specific hospital or physician group.

O

Out-of-network
Healthcare professionals, hospitals or pharmacies that are not listed as preferred providers by your plan. Your insurance will pay the least for out-of-network providers.

Out-of-pocket (OOP) costs
OOP costs include what your health insurance charges you and expenses that are not covered by your insurance. These include copayments, co-insurance, deductibles and the cost for non-covered services.

Out-of-pocket maximum
The OOP maximum is the most that you have to pay for covered services in a year. After you have paid your OOP, your plan will pay 100% of the costs of covered benefits. The OOP maximum does not include monthly premiums or non-covered services.

P

Payer/Payor
The insurance company that pays for your cost of health services.

Policy number/Member ID
The ID number assigned to you. You can find this number on your insurance ID card. It allows providers and your insurance company to review the details of your plan.

Precertification/Prior authorization
The process that helps determine if your care is medically necessary and should be covered by your insurance company. Your plan may require prior authorization before receiving certain services. You do not need prior authorization before emergency services.

Premium
The set amount that you will pay—usually each month—for your health insurance coverage.

Primary Care Provider (PCP)
A provider who practices general healthcare and monitors your overall health. They are usually your first stop for receiving care.

Provider
Any person or organization who provides healthcare. Providers include entities such as doctors, hospitals and urgent care clinics.

R

Referral
Your primary care provider (PCP) may send you to another doctor or specialist for care. For example, if your PCP thinks you need to see an eye doctor, they can give you a referral, so your health insurance can help pay for it.

S

Subscriber (member or enrollee)
A subscriber is the main person enrolled in the health insurance plan. If you have a family plan, the subscriber is the person in charge of the insurance. Other family members, like a husband, wife or kids, are called dependents.

T

Third-party payer
A payer other than you that pays for your healthcare expenses, such as the government or your employer.

Tiers
A tiered network further categorizes in-network providers or services, which may affect how much you pay. For example, a provider in Tier 1 of a plan may cost less than a provider in Tier 2.