Health is an important coverage that helps protect you and your family from the devastating financial effects of unexpected health problems or catastrophic illness and as of January 1, 2014, most Americans are now required by Federal Law to have health insurance or pay a penalty.
The Oklahoma Insurance Department encourages you to work with the insurance professionals in your community to help you determine the appropriate policy for your family or business needs. These insurance professionals can be found on our website under:
Federal Health Care Reform Resources
You may receive health coverage through an individual insurance policy, through a policy issued to you as a member of an association group, through an employer sponsored health plan or through a government plan (Medicare, Sooner Care (Medicaid), VA, etc.). If your employer sponsored health plan is “self insured” it is not subject to regulation by the Oklahoma Insurance Department but regulated by the Department of Labor. Additional information regarding employer sponsored plans is available below. The three main types of health insurance are:
Policies that offer traditional health insurance;
Policies that provide managed care services; and
Policies that provide limited benefits.
2023 Affordable Care Act Health Insurance Rate Filings
Traditional Health Insurance
With the passage for the Affordable Care Act or Healthcare Reform in 2010, most traditional health insurance plans, often called “fee-for-service,” are most likely now to be found in “Grandfathered Plans”, non-compliant ACA plans or commonly known as “Grandmother Plans” or Medicare Supplement Plans. If your plan is a true “free for service”:
You can use any doctor or hospital.
You send your medical bills to the insurance company (the provider may do this for you but is not required).
You will likely have to pay a deductible to your provider before the policy begins to pay and co-payments to your provider each time you visit your provider or doctor’s office.
If the policy pays less than the full bill, you most likely will be responsible for paying the balance.
ACA compliant group health and individual policies fall under the category of comprehensive medical policies. These ACA compliant policies are expensive because they are required by Federal law to provide more benefits than many older or pre-ACA policies. An ACA compliant policy pays a percentage of covered expenses (for example, 60%, 70%, 80% or 90%), after you pay the applicable plan deductible and copays. The remaining expense (for example,10%, 20%, 30% or 40%) is coinsurance and is paid by you. Maximum out-of-pocket limits restrict the amount of coinsurance you pay. After the covered person or family reaches their maximum out-of-pocket limit, your plan will pay 100% for that person or family for the rest of that year. Pay particular attention to the plan’s maximum out of pocket limit before you buy a plan particularly if you are not eligible for cost sharing reductions on the federal exchange.
Policies that provide Managed Care Services
ACA compliant policies will often be tied to a provider care network. This affects your choice of doctors and hospitals because not all providers are part of the network. In return for this limited choice, you usually pay less for medical care (i.e., doctor visits, prescriptions, surgery and other covered benefits) than you would with traditional “fee-for-service” health insurance. The managed care network controls health care services in these narrower network options Be sure to review all providers available to you under each type of Managed Care Service network you choose.
If your health care provider is out-of-network, you are responsible for the difference between the allowed amount and the provider’s charge and those amounts will not be applied toward your out-of-pocket limits. It is imperative that you contact your insurer should you have any question regarding a health provider being an in-network or out-of-network provider. Out- of- network providers can be far more costly as they are not subject to your insurer’s provider contract/s or discounted fee for services, however ACA compliant polices must cover emergency services received by an out-of-network provider as if they were in-network.
The types of Managed Care Networks are:
- Preferred Provider Organizations (PPOs) – PPOs offer a provider network to meet the health care needs of an insurance carrier’s insureds. The insurer contracts with a group of health care providers, or with a PPO network, to control the cost of providing benefits to their insureds. These providers charge lower-than-usual fees because they require prompt payment and serve a greater number of patients. Insured’s usually choose who will provide their health care, but pay less in coinsurance with a preferred provider than with a non-preferred provider.
- Health Maintenance Organization (HMO) – HMO members pay a monthly fixed dollar amount (similar to an insurance premium), which gives them access to a wide range of health care services. In many cases, members also pay a predetermined amount, or copayment, for each doctor or emergency room visit and for prescription drugs, rather than paying the provider in full and obtaining a portion of the reimbursement later. Members must use the HMO’s network of providers, which may include the doctors, pharmacies and hospitals under contract with that particular HMO.
- Point of Service plans (POS) – In a POS plan, insured members may choose, at the point of service, whether to receive care from a physician within the plan’s network or to go out of the network for services. The POS plan provides less coverage for health care expenses provided outside the network than for expenses incurred within the network. Also, the POS plan will usually require you to pay deductibles and coinsurance costs for medical care received out of network.
Limited Benefit Coverage Plans
- Limited benefit health plans are insurance products with reduced benefits intended to supplement comprehensive health insurance plans, not to be an alternative to them. You may have seen these types of plans marketed as Short Term Limited Duration Insurance, Accident Policy, Cancer Only, Specific Disease or Heart Policies, Hospital Cash or Indemnity plans. They may also be Discounted Plans such as Pharmacy, Dental or Medical Clinic Memberships. These plans are not considered ACA compliant which could result in you paying additional out-of-pocket expenses for uncovered medical services.
- Limited benefit health insurance plans are not typically required to provide the same level of coverage, so they cover fewer types of medical services and expenses than a comprehensive policy. They are not required to cover your pre-existing conditions. These plans typically pay you a flat amount for a specific service, covered item or covered disease or giving you a discount for services, leaving you the rest of the bill to pay yourself. A limited benefit plan may limit the amount of coverage the company will pay per episode of illness or per day, sometimes as low as $50 to $5,000 (not counting co-insurance and deductibles paid out-of-pocket by you). These policies also provide limited surgical, preventative care, testing and emergency benefits upon receipt of the billing. And with low maximum benefit limits called “caps,” it may be possible for you to reach your cap quickly, leaving you responsible for the balance of the bill. Discounted plans still leave you paying for the services yourself.
