Health Insurance Terminology
The amount of money you and your family pay each month to the insurance company to keep health coverage.
The amount of money you or your family is responsive for when paying the medical care you received. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.
The set amount you must pay for covered health care services before your insurance plan starts to pay. For example, if you have a $2,000 deductible, you pay the first $2,000 of covered services yourself. The spending beyond the deductible are paid for by the insurer, you usually pay only a copayment or coinsurance for covered services.
Understanding Affordable Care Act (aka. Obama care)
It's a refundable tax credit based on your family size and income on your tax return. If your household income is below 400% of the FPL, and you purchased a Silver plan, you can expect to receive tax credit, which will help you reduce your monthly premium.
These are the 4 types of health plans offered on the health exchange market based on the level of coverage. Bronze plans cover 60% of your covered health care expenses; Silver plans cover 70%, Gold plans cover 80% and Platinum plans cover 90%. As you go up the metal tier, you will have lower Out of Pocket spending, but you will also be paying for a higher monthly premium. There is also a Catastrophic plan tier for low cost plans that cover people under the age of 30.
Even if you think you are healthy today, you never know what's going to happen tomorrow. You might have a sudden or serious illness (cancer, appendicitis) or a traumatic event (ski accident, car crash). Without insurance coverage, you can easily be spending thousands of dollars. The inability to pay high medical bills is one of the most common reasons people file for personal bankruptcy. Purchase the right health insurance will protect you in all situations.
You may incur penalties for not having health insurance: In 2016, the fine is $695, or approximately 2.5% of your income, whichever is higher.
You can only purchase health plan during the open enrollment period each year, unless you have a qualifying event during the year. Open enrollment for the coverage in 2017 is from November 1 2016 to January 31, 2017. Employees working for small employers may be allowed to enroll anytime during the year.
You may incur penalties for not having health insurance: In 2016, the fine is $695, or approximately 2.5% of your income, whichever is higher.
You may incur penalties for not having health insurance: In 2016, the fine is $695, or approximately 2.5% of your income, whichever is higher.
They are 3 most common types of qualifying life event: 1. loss health coverage: this could be job based or government program. 2. change in household size: getting married or having babies. 3. change location: move in/out of the original state. This is not a complete list. Please contact us if you are unsure about your situation.
Medicaid is a government funded health insurance program for low-income and needy people. It covers children, the aged, blind, and/or disabled and other people who are eligible to receive federally assisted income maintenance payments. In most states, people earning less than $16,394 in 2016 (138% of the federal poverty level) are eligible for Medicaid coverage. You can see whether you are eligible by completing our questions (hyperlink URL to page 2).
Similar to Medicaid, CHIP is a program that provides health insurance to children in low-income families. In most states, children from families earning less than 200% of the FPL are eligible for CHIP coverage. You can see whether you are eligible by completing our questions (hyperlink URL to page 2).
It is another form of government assistance that's provided for individuals with income below 25% FPL (Federal Poverty Level). If you belong to this group, you can get extra savings on your Out-of-Pocket health care costs, such as copay/coinsurance. But you get these extra savings only if you enroll in a Silver plan. For example, if your income is 150% FPL and you pick a Silver plan, you’ll receive the premium tax credit to lower your monthly premium and the extra cost sharing assist to lower your copay/coinsurance whenever you go to the doctor or use other medical services.
Majority of the people shopping on the health exchange will choose a Silver plan because this is the only metal plan that provides government assistant (premium tax credit and cost sharing reduction) if they meet the criteria.
It is a measure of income issued every year by the Department of Health and Human Services. It varies depending on your family size. The level changes slightly every year. It is used to determine Medicaid and CHIP eligibility and if you are qualify for government assistance when buying insurance through state or federal health insurance marketplace. Please click here to see the detail numbers for 2016.
Understanding your pharmacy benefit
Generic and Brand medications have the same active ingredient, but different inactive ingredients . They are made by different manufacturers. So they may look different but do the same job.
It takes on average 20 years for drug companies to discover and successfully bring a new Brand medication to the market. The FDA (Food and Drug Administration) issues a patent to all Brand drugs, which last anywhere from 10-20 years. During this time, no other manufacturers can make the same medication. The price of the brand medication is set by the original manufacture alone. This allows the pharmaceutical company to generate revenue to cover what they paid to discover the drug. When the patent expires, other drug companies can make the same drug using the same active ingredient. Generic drugs are much cheaper because these drug companies didn't go through the expensive drug development process, and multiple drug companies will be making the same drug at the same time.
Health plans place brand name medications based on cost and efficacy into two lists: preferred and non-preferred. You will pay less copay/coinsurance for drugs on the preferred list. Drugs on the non-preferred list have the highest copay/coinsurance. In most cases, a cheaper alternative drug (generic or preferred drug) is available. Most drugs that recently came onto the market and still under patent protection will fall under the non-preferred list.
A formulary is a list of medications that are covered by the health plan. Health plans usually do not pay for medications that are not on this list.
Drugs on a formulary are typically grouped into tiers. The tier that your medication is in determines your portion of the drug cost sharing. A typical drug benefit includes four tiers: Tier 1 usually includes generic medications. Tier 2 usually includes preferred brand name medications. Tier 3 usually includes non-preferred brand name medications. Tier 4 usually includes specialty medications. Typically, drugs in the higher tiers are more costly. The higher the tier, the higher the copay amount.
A copayment is a set amount you pay whenever you fill a prescription. e.g. if your benefit states you have a $10 copay, that means you will be responsible for $10 each time you fill your prescription, regardless how much the drug actually cost. Your health insurance company pays the rest of the bill. Coinsurance is a percentage of the total cost of prescriptions you fill. E.g. if your benefit states you have a 25% coinsurance, that means you will be responsive for 25% of the cost of the drug, and your insurance company will pay the remaining 75%. If the drug costs $500 per prescription, you will pay $125 each time you fill the prescription. However if the drug costs $100 prescription, you will only pay $25 each time you fill the prescription.
The health plan may require you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition.
Step therapy is type of PA. It's used when there are effective, lower-cost drugs that treat the same medical condition as yours. You may be required to try one or more of these other drugs before you can move up a "step" to a more expensive drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug. Our plan comparison page lists whether a drug has step therapy requirement on the health plans.
For safety and cost reasons, plans may set quantity limits on the amount of drugs they cover over a certain period of time. For example, a person may be prescribed a medication to take two tablets per day, or 60 tablets per month. If the plan has a quantity limit of 30 tablets per month for that medication, your doctor or prescriber will need contact the health plan to provide the medical reason for the higher quantity. Health plans will review the information and give you a PA if it is considered medically necessary. Our plan comparison page lists whether a drug has quantity restrictions on a health plan.
Health plans decide which drugs they include in their drug formularies. Items outside of that list will typically not be paid for by the health plan. This may be because there are cheaper and effective drugs. You must pay out of pocket if you decide to receive the drug that's not covered by your health plan. Our plan ranking system will place plans that provide the best cover for all your medication needs higher than plans that do not cover all your drugs.
Based on medications you entered, CleaRx selects cheaper drugs that have the same/similar effect. We do this by using a methodology we developed, first we scans all available drugs to identify the active ingredient and therapeutic effect of your drug, and selects where available the cheapest alternative for you. This may be generic or another brand drug. You can either switch all of your medications or some of them. We let you decide which drug(s) you wish to switch and will give you the cheapest alternatives for each drug you selected. You will see an updated plan ranking afterwards, and the details of the alternatives we suggested in the plan detail page.
While we help you identify cheaper alternatives to your current medication, it is important that you consult with your doctor before making these switches. We make this simple by generating a letter that explains the switches to your doctor. You can either email to your doctor or print it out to take with you to your next office visit.
General Question about CleaRx
Creating an account give you the convenience of having your past searches saved so you will not have to re-enter all your information each time. Once the account is created, you can leave comments/reviews for the health plan and share experience with other users. Also, from time to time, we will send you helpful information that is relevant to your medical conditions and prescription needs.
A lot of people find it hard to find prescription coverage information when selecting health plan at the marketplace. They often chose a plan without knowing if their drugs are covered and what are their copays. As a result, they may be surprised to find that the drugs they take are either not covered by the health plan they chose or have very high out of pocket costs. CleaRx provides a simple to use platform that ranks all available health plans in your area based on your prescription needs. We can also help you find cheaper drug alternatives if available. You will also be able to view and submit reviews for each health plan.
We partnered with GoodRx to obtain our cash prices for each drug. GoodRX provides the lowest price you should be expected to pay at a retail pharmacy when you do not have health insurance coverage.
We obtained health plan ratings from two places, NCQA that rates health plans by conducting consumer surveys and from reviews by our own users like you.
We obtained the drug ratings from our partner Iodine. Iodine gathers reviews from thousands of patients about their experience taking each drug.
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