Benefits and Qualifications

Whether you're looking to buy health insurance or are thinking of switching plans, understanding the differences between plan types streamlines medical processes while ensuring maximum coverage. Where personal care and external solutions are considered, the Affordable Care Act (ACA) offers consumers with a variety of specified benefits, too.

Individuals seeking coverage often wonder about policy protection and payments. Health insurance coverage benefits are often received depending upon a variety of factors, including:

  • Membership in "managed care" plans
  • Previous health history
  • Need for specialized care

These qualifications often adhere individual plans to specified coverage. However, individual health insurance plans often deliver many benefits, such as:

  • Preferred Provider Organization (PPO) plans offer network-external services. Often, a percentage of internal coverage is provided based upon the individual's situation. Lower deductibles are available.
  • Health Maintenance Organization (HMO) plans offer a contract between an insurance company and the individual patient. This contract grants great coverage for hospital, doctor and network-approved providers.
  • Point of Service (POS) providers are incredibly open-ended. They're considered a "PPO and HMO hybrid plan." These plans grant primary caregivers, and they offer availability to opt-out of network provider services with co-payment increases.

Coinsurance Maximum Qualifications

Normally, every individual is granted the right to organizational health insurance. While funds may be an issue, previous health maladies only determine coverage amounts, rather than coverage itself.

However, insurance qualifications often run unilaterally to coinsurance maximums, or the "annual cap" individuals are required to meet. Individuals will not be able to pay medical bills without procuring the maximum amount. Similarly, several other requirements must be met:

  • Procurement of "out-of-pocket" maximums
  • Procurement of a deductible or, the upfront amount required for service
  • Responsibility of co-insurance

Additionally, individual and family plans often require percentage-payments for several areas, such as physical therapy, prescription drugs, nursing care, x-rays and lab tests. Depending upon a policy's specifications, individuals may be responsible for payment.

The Affordable Care Act

The ACA, while a provisionary law, offers essential benefits to individuals within the new health insurance marketplace:

  • Prescription drugs are covered with minimal extra costs
  • Ambulatory patient services (outpatient care) are granted immediately. Nearly every individual and family insurance plan provides such coverage
  • Hospitalization is offered through individual and family insurers. While the holder may require about 20 percent of the bill, the ACA can help costs by offering financial assistance and subsidies
  • Most plans cover Emergency care, and ER room visits don't require pre-authorization. Extra costs are not applied to out-of-network ER visits.
  • Rehabilitative services grant rehabilitative therapies relieving pain, handicaps and life-required mobility supplies

Open Enrollment Availability

Open enrollment is an annual period when individuals can apply for health insurance plans. Individuals and families without plans during open enrollment are often not granted an opportunity to apply for the year's insurance. Normally, they're barred from application until the next year.

Pre-Existing Conditions

Having pre-existing conditions, such as high blood pressure, diabetes or depression needn't pose problems for those seeking health insurance solutions. According to the ACA, insurance companies may not turn away individuals based upon medical conditions. Similarly, patients are not required additional wait times before coverage is provided.