Your handbook📕 to health insurance.

An event, such as a loss of health care coverage (hello, turning 26 🎂), changes in household (like marriage 💒 or having a baby 👶), or changes in residence (moving somewhere new ✈️).

If you experience a qualifying life event, then you can participate in a Special Enrollment Period (SEP) and find an insurance plan that works for you. If you haven’t experienced a QLE, you have to wait for the Open Enrollment Period (which typically begins November 1st and ends mid-January in most states).

Your copay is a flat-dollar amount that you’ll pay when visiting a healthcare provider. So, for example, if your copay for an annual check-up is $50, you’ll pay $50 at the time of your appointment.

Your deductible is the dollar amount that you’ll pay for healthcare services every year—before your insurer will start paying claims under your policy.

In-network providers are contracted to be part of the network for a “managed care organization,” such as an HMO or PPO (more on that next).

Out-of-network providers, which can include hospitals, doctors, or other healthcare experts, don’t have a contract with your healthcare—so this means you’ll be responsible for more of the costs if you choose to go out-of-network.

Not to be confused with out-of-network, your out-of-pocket maximum is the absolute limit of money you’ll pay in a calendar year for health care, excluding what you pay as your health insurance premium. Out-of-pocket maximum includes both your copays (a flat-dollar amount) and your deductible (the dollar amount you’ll pay out-of-pocket before your insurer will pay claims). Consider this your financial safety net. In the event of an emergency, this number is the maximum (read: worst-case scenario) of what you’ll have to pay.

If you have pre-existing conditions or prescriptions, it’s important to understand that health plans negotiate the rate they’ll pay the drug company or pharmacy benefits manager. Medications 💊 are then divided into tiered plans: Tier I medications are less expensive and have smaller copays in comparison to Tier 3 Medications, which are more expensive and have higher copays. Every time your prescription is filled, you pay your copay.

A referral is a “written order” your physician 🥼 signs for you to receive certain medical services or receive the support of a specialist. Understand that just because your physician has made a referral does not mean that your insurance has approved it.

Four ways to refer to the same process. Your health insurance plan may require you to get pre-authorization ✍️ for services before you receive them. But remember: Preauthorization is not a promise that your health insurance plan will cover the cost of the service. 

PPO, which stands for Preferred Provider Organization, is a type of health insurance plan that offers a network of healthcare providers—such as doctors, hospitals, and specialists. PPO plans typically offer a mix of both deductibles and copayments.

Another common type of health insurance plan is an HMO, which stands for Health Maintenance Organization. This plan typically requires you to select a primary care physician (PCP) from a network of healthcare providers. Your PCP then serves as your point of contact for managing your healthcare needs 🧑💻. For example, if you need to see a specialist, your PCP will provide a referral. HMO plans tend to have lower out-of-pocket costs.

An HSA is a tax-advantaged savings account that is available if you’re enrolled in a high-deductible health plan. An HSA allows you to save money for medical expenses not covered by your insurance plan. All contributions you make to your HSA are tax-deductible, and any interest or investment earnings on your account are also tax-free.

An FSA is another popular savings account with healthcare benefits. Unlike HSAs, which allow you to “roll over” unused funds from year to year, your FSA operates as a “use-it-or-lose-it” account. Any funds remaining in your account at the end of the year will be forfeited. Similarly to an HSA, any withdrawals from your FSA are tax-free. FSAs are available to anyone whose employer offers them—regardless of the type of health insurance plan you may have.

A primary care provider (PCP) for yourself and your family may be a family doctor, nurse practitioner, pediatrician, OB/GYN, or other provider.  

Your PCP helps you get the care you need. Your PCP can give you many health care services such as: 
• Yearly check-ups
• Shots
• Sick visits 
• Health screenings

Your PCP will get to know you and your health history, habits, and goals. Your PCP:
• Gives you primary care
• Helps you manage health issues like asthma, obesity, diabetes, and high blood pressure
• Refers you to a specialist when you need one