Senior Direct Insurance Solutions

Essential Health Benefits

Under the Affordable Care Act (ACA), fully insured small group and individual health plans on and off the Exchange/Marketplace must cover essential health benefits (EHB).

Essential health benefits are minimum requirements for all plans in the Marketplace. Plans may offer additional coverage. You will see exactly what each plan offers when you compare them side-by-side in the Marketplace.

Essential health benefits under the Patient Protection and Affordable Care Act will include the following general categories:

  • These essential health benefits include at least the following items and services:
  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization
  • Maternity and newborn care (care before and after your baby is born)
  • 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

According to the Affordable Care Act, plans of all sizes that cover benefits designated as Essential Health Benefits, including self-funded plans, must cover these benefits with no annual limits or lifetime maximums.

Footnote: This is a brief overview of the Essential Health Benefits required by the Affordable Care Act. You should read thoroughly and understand the benefits offered before purchasing any insurance policy.

What You Need to Know About Health Insurance

What You Need To Know About Health Insurance

Accidents and illnesses can happen to anyone at any time. No one plans to get sick or hurt, but most people need medical care at some point. Health insurance covers these costs and protects you from very high expenses.

Health coverage when you need care

Simply put, health insurance is a contract between you and your insurance company. You buy a plan, and the company agrees to pay part of your medical costs when you get sick or hurt. However, it’s not really that simple. You need to consider what is right for you and your family, your out-of-pocket costs, and your monthly premium.

Under the Affordable Care Act, plans available in the Marketplace (and most other plans) provide free preventive care, like vaccines, screenings, and check-ups. They also cover some costs for prescription drugs.

Health insurance protects you from the unexpected

An average one-day hospital stay is *$2,271. Most of us can’t afford even one day at the hospital without having it impact our financial stability. Health coverage can help protect you from high, unexpected costs like these.

How health insurance coverage works

  • Premium: A premium is a fixed amount you pay to your insurance plan, usually every month. You pay this even if you don’t use medical care that month.
  • Deductible: If you need medical care, a deductible is an amount you pay for care before the insurance company starts to pay its share. Once you meet your deductible, your insurance company begins to cover some costs of your care. Some plans have lower deductibles, like $250. Some have higher deductibles, like $2000.
  • Co-payment: A co-payment is a fixed amount you’ll pay for a medical service after you’ve met your deductible. For example, after meeting your deductible you may pay $25 for a visit to the doctor’s office that would cost $150 if you didn’t have coverage. The health plan pays the rest.
  • Co-insurance: Co-insurance is similar to co-payment, except it’s a percentage of costs you pay. For instance, you may pay 20% of the cost of a $100 medical bill. So you would pay $20 and the health plan would pay the rest after you have paid your calendar year deductible.

How insurance protects you insurance coverage from high medical costs:

  • Out-of-pocket maximum: This is the total amount you’ll have to pay if you get sick. For example, if your plan has a $3000 out-of-pocket maximum, once you pay $3000 in deductibles, coinsurance, and co-payments the plan will pay for any covered care above that amount for the rest of the year.
  • No yearly or lifetime limits: Health plans in the Marketplace can’t put dollar limits on how much they will spend each year or during your lifetime to cover essential health benefits. After you’ve reached your out-of-pocket maximum, your insurance company must pay for all of your covered medical care with no limit.

Going without health insurance can put you at serious financial risk. It is important to consider your options. Keep in mind that if you or someone in your family suffers from an illness or accident this can sometimes lead people without coverage into deep debt or even into bankruptcy.

Don’t let that happen to you. For more information visit

*2015 Kaiser Foundation

Short-Term Medical Insurance – Temporary Coverage

Outside of the individual market’s annual open enrollment period a short-term health insurance policy might be your best option, especially without a qualifying event. Short-term plans generally provide the most comprehensive coverage available outside of the open enrollment

Short-term policies have been around for some time. They are a good option for people who are between jobs or waiting for a new employer’s coverage to become effective. Unlike regular individual major medical plans, short-term health insurance policies are not regulated by the Affordable Care Act and their sale is not limited to open enrollment windows.

When does a short-term policy make a lot of sense?

If you experience a qualifying event that triggers a special enrollment period, you’ll need to apply for an ACA-compliant policy (on or off-exchange) during your special open enrollment period, which lasts for 60 days in most cases. If you opt for a short-term policy instead, you won’t have the option to switch to an ACA-compliant plan after your open enrollment period ends. But, if you miss open enrollment and haven’t experienced a qualifying event, a short-term policy will provide you with up to six months of coverage in most states.

Short-term plans are typically offered with a selection of premiums, deductibles, and benefit maximums. The policies are considerably less expensive than ACA-compliant major medical plans, so you may find that you can afford to purchase a plan with a low deductible and a high benefit maximum. Plus, healthy applicants can secure immediate individual and family coverage, with plans that can start almost immediately. 

The policies also cover a range of physician services, surgery, outpatient, and inpatient care. In addition, policyholders can often choose their own doctor and hospital without restrictions, though there may be financial incentives for using in-network providers.

What Short-Term Health Insurance Won’t Cover

Short-term major medical plans may be a great fit for healthy folks who just need temporary coverage, but the plans weren’t designed to cover everything, and they do not provide coverage for all of the ACA’s essential benefits.

They typically won’t cover your routine office visits, maternity, mental health or preventative care – and they won’t cover preexisting conditions. They also still use medical underwriting, which means that applicants with serious pre-existing conditions may not be able to get short-term coverage. Be sure to check the list of exclusions on any policy.

Give me a call to find out if short-term health insurance is an option for you.

Pre-65 Health Care Insurance

If you’re under the age of 65 and need health insurance, there are 4 basic options available to you. We can help you determine the right choice based on your budget and needs.

On-Exchange Plans (OBAMA CARE – Affordable Care Act)
The plans are administered through the Centers for Medicare and Medicaid. Many people qualify for subsidies based on qualifying factors to help with their health care costs. This is typically the first step in finding the right plan for you and we’ll guide you thru the process step by step.

Off-Exchange Plans
If you don’t qualify for a subsidy you can purchase health insurance directly from a carrier. We can help you compare plans and enroll in one that best meets your needs and budget.

Short-term major medical
These types of plans are a great alternative for consumers looking for major medical coverage.  Short Term health insurance, sometimes called Term health insurance or Temporary health insurance, is designed to bridge gaps in your health care coverage during times of transition. These plans allow you to:

  • Start your coverage fast, as soon as the next day in many cases.
  • Drop your coverage without penalty.
  • Choose from a range of available deductible amounts.
  • Apply for another term of coverage if needed.

Hospital Indemnity Insurance
Hospital indemnity insurance is a type of plan that pays a set amount – per day, per week, per month, or per visit. In addition to a hospital per diem, a more comprehensive plan might feature payments for an ambulance trip, surgery or maternity visit, or increased payments for intense ailments such as stroke or cancer. Benefits can disburse in lump sums for short admittances or on a daily or weekly basis during longer visits.

As you can see, there are many options to choose from with different benefits and payment methods. We’re here to help you through the confusion. Contact us today!

What is a Health Insurance Marketplace?

This year the enrollment period is shorter than in previous years, so it’s important to act quickly. If you don’t act by December 15, you can’t get 2018 coverage unless you qualify for a Special Enrollment Period. Plans sold during Open Enrollment start January 1, 2018.

Every health insurance option in the Marketplace will offer comprehensive coverage, from doctors to medications to hospital visits. You can compare all your insurance options based on:

  • price,
  • benefits,
  • quality, and
  • other features that may be important to you.

Insurance Coverage Run By Private Companies

When you shop at the Marketplace, coverage information will be laid out for you. All your costs are stated up front, so you’ll get a clear picture of what you pay and what coverage you receive before you make a choice. Health insurance companies can’t refuse to cover you or charge you more just because you have a chronic or pre-existing condition, and they can’t charge more for women than for men.

You May Save On Your Monthly Premiums

When you apply for coverage in the Health Insurance Marketplace, you’ll find out if you qualify for a premium tax credit to help lower your premium, which is the amount you pay each month to your insurance plan. The amount of your premium tax credit depends on the estimated household income for 2018 that you put on your Marketplace application.

Find out if your estimated 2018 income is in the range to qualify for a premium tax credit.

Coverage falls into four categories

The category you choose affects how much your premium costs each month and what portion of the bill you pay for things like hospital visits or prescription medications. It also affects your out-of-pocket costs —the total amount you’ll spend for the year if you need care. The categories are

  • Bronze
  • Silver
  • Gold
  • Platinum

The Marketplace also offers “catastrophic” policies to people under 30 years old and to some people with very low incomes.

Balancing Monthly Premiums With Out-Of-Pocket Costs

As with all health coverage, you will still have to pay a monthly premium.

  • Premiums are usually higher for policies that pay more of your out-of-pocket medical costs when you get care. For example, if you have a Gold policy, you’ll likely pay a higher premium, but may have lower costs when you go to the doctor or use another medical service.
  • With a Bronze policy, you’ll likely pay a lower premium, but you’ll pay a higher share of costs when you get care.
  • The platinum policy will likely have the highest monthly premiums and lowest out-of-pocket costs.

The policy will pay more of the costs if you need a lot of medical care.

In general, when choosing your health coverage, keep this in mind:

  • the lower the premium, the higher the out-of-pocket costs when you need care;
  • the higher the premium, the lower the out-of-pocket costs when you need care.