The New No Surprises Act and Health Insurance 101

There are many moving parts to a Health Insurance policy.  There are Premiums, APTC’s, deductibles, Copayments, Co-Insurance, and Maximum Out of pocket expenses or MOOP, SEP, and balance billing issues. Before we go into Health Insurance lingo, Let’s talk about a law that was just passed that will really help Healthcare consumers and hopefully will stop the abuses when it comes to coverage and billing. Now that the “No Surprises Act” has been passed providers must produce a good faith estimate upon the members request and may be held responsible if they refer their patient to a provider that is out of the patients Health plan network. What does this all mean to the consumer?  Up until this bill being passed many Healthcare consumers that were referred to out of network providers were getting billed for the balance of charges the Insurance Company did not cover.  With The “No Surprises Act” having been passed effective January 1st 2022, a consumer can request a Good Faith Estimate of expected charges and if a Healthcare consumer unknowingly gets medical care from a provider or facility outside their Health Plan’s network they can dispute the charges. A Help Desk has now been set up to help consumers. The number is 1-800-985-3059  8am to 8pm EST 7 days a week. Their web address is:  It’s about time the Government passes this type of consumer protection law. It was much needed and long overdue.  
Let’s get into Health Insurance terminology in the order in which they happen:  
1. Premium, APTC, & SEP-The “Premium” is the monthly amount you pay for your Health Ins plan.  If you qualify, the monthly premium you pay may be reduced by the “APTC” or the Advanced Premium Tax Credit.  The APTC is based on your annual household income and is projected for the current plan year. There are many “SEP” or Special Enrollment Period opportunities where one can enroll in coverage in between the Annual Open Enrollment period, sometimes referred to as the Blackout period. Call an agent or myself and we can determine if you are eligible and how much help you would get paying for your Health Insurance.  Once your plan is set up, a monthly Auto-Pay program is always recommended .vs receiving a paper invoice in the mail. This way you know your premium is coming out of your bank account automatically and you don’t risk having a lapse in your coverage.
2. Deductible-The deductible is the amount you pay out of pocket before the policy starts to pay. Think of your Auto Insurance collision deductible. Let’s say it’s $500.00 and you’re involved in an accident where you damage your vehicle. You must pay the $500 deductible before your Automobile Insurance Company covers your damage. The same is true for Health Insurance. You must meet your Health Insurance deductible before the policy starts to pay.
Now, once you have met your deductible then you may also have a Co-insurance responsibility until you reach the MOOP or Maximum Out of pocket limit for your plan.  The most common annual Out of Pocket limit on Marketplace plans for Plan year 2022 is $8,700.00 and once you’ve paid that out of pocket most plans will pick up 100% thereafter.  So, really the Deductible, Co-insurance, and Maximum Out of Pocket expenses work closely together. Let’s look at an example: A plan member goes into the hospital for a pre-authorized Gallbladder surgery.  He has an HMO with a $3000 deductible and 40% Co-Insurance, and an $8,700 Maximum Out of pocket limit.  Let’s assume the total cost for the surgery is $40,000.  This patient/plan member will pay the first $3000 because that’s the deductible. He will then be responsible for paying 40% of charges. Once his $3000 and his 40% Coinsurance responsibility reaches $8700 it is at that point that the Insurance Company picks up 100% until the end of the policy period.  Doctor, Specialist, & Urgent Care visits usually have set copayments and are not subject to Deductible or Coinsurance and goes toward the Maximum Out of Pocket expenses.

Call Gary to discuss your best options.

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