Health Insurance Basics, Enrollment and ICHRA FAQs: Plain-English Answers on Costs and Coverage
These answers cover health insurance basics, from premiums and deductibles to enrollment, subsidies and ICHRA. Licensed Vivna agents wrote each one in plain English. Because rules can change by state, every answer shows where it applies. Call 888-730-6001 anytime for free help.
Vivna Insurance is an independent, licensed agency appointed with 50+ carriers nationwide. Plans, benefits and availability vary by state.
Health Insurance Basics and Key Terms
Start here to learn how health insurance works and what common terms mean. Then move on to costs.
β What is health insurance?
Health insurance is a contract where your insurer pays some or all of your health care costs.
In exchange, you pay a premium.
π Where this applies: Every state Vivna serves
β Why do I need health insurance?
Health insurance helps pay for medical care for you and your covered dependents.
Without it, you may pay the full cost of all your care. That can be very expensive.
π Where this applies: Every state Vivna serves
β How does health insurance work, step by step?
You pay a premium, usually monthly, then share costs with your plan after the deductible.
Until you meet your deductible, you pay for care yourself. After that, you and your plan share costs through coinsurance. Typically, preventive care is covered at 100%.
π Where this applies: Every state Vivna serves
β How does health insurance help me catch health problems early?
Having a plan encourages you to get your annual check-up and other preventive care.
That helps find health issues early, before they become serious. In addition, most plans cover certain in-network preventive care at 100%.
π Where this applies: Every state Vivna serves
β Who are individual and family health plans for?
Individual and family health plans are for people not connected to job-based coverage.
State law regulates individual policies. Also, you can buy them through the Health Insurance Marketplace.
π Where this applies: Every state Vivna serves
β Can I buy health insurance if my job does not offer it?
Yes, you can buy a plan on your own through a state or federal health exchange.
You can also buy from a licensed broker or directly from an insurance company.
π Where this applies: Every state Vivna serves
β What is the Affordable Care Act (ACA)?
The ACA is the federal health care reform law, also called PPACA or Obamacare.
Its main goal is making affordable health insurance available to more people. In addition, it created subsidies called premium tax credits.
π Where this applies: Every state Vivna serves
β Is Obamacare the same thing as the ACA?
Yes, Obamacare is a common nickname for the Affordable Care Act.
You can buy ACA plans through the Health Insurance Marketplace, also called the exchange.
π Where this applies: Every state Vivna serves
β Are ACA plans for individuals regulated by my state?
Yes, individual health insurance policies are regulated under state law.
That is one reason plan options and rules can differ from state to state.
π Where this applies: Every state Vivna serves
β What is a dependent for health insurance?
A dependent is a child or other person you may claim on your taxes as a personal exemption.
Covered dependents can also be on your health plan.
π Where this applies: Every state Vivna serves
β What is an individual and family health insurance policy?
An individual and family policy is for people not connected to job-based coverage.
In addition, state law regulates these policies.
π Where this applies: Every state Vivna serves
β What are health plan categories?
Health plan categories are the Marketplace metal levels: Bronze, Silver, Gold and Platinum.
They show how you and your plan split costs, not quality of care.
π Where this applies: Every state Vivna serves
β What does OEP mean in health insurance?
In health insurance, OEP stands for Open Enrollment Period.
It is the yearly fall window to enroll in a plan for the next calendar year.
π Where this applies: Every state Vivna serves
β What does QLE mean in health insurance?
In health insurance, QLE stands for qualifying life event.
It is a change, for example marriage or a new baby, that can open a Special Enrollment Period.
π Where this applies: Every state Vivna serves
β What does APTC stand for?
APTC stands for Advance Premium Tax Credit.
It lets you apply your tax credit up front to lower your monthly premium.
π Where this applies: Every state Vivna serves
β What does CSR stand for in health insurance?
In health insurance, CSR stands for cost-sharing reduction.
It lowers your deductibles, copays and coinsurance on a Silver plan if you qualify.
π Where this applies: Every state Vivna serves
Premiums, Deductibles and Cost-Sharing
These answers explain premiums, deductibles, copays and coinsurance. As a result, you can compare plans by total cost.
β What is a deductible?
A deductible is the amount you pay each year for covered care before your plan starts helping.
Once you meet it, your plan begins sharing costs with you.
π Where this applies: Every state Vivna serves
β What is the difference between an individual deductible and a family deductible?
An individual deductible is what one person must pay before cost-sharing kicks in for them.
By contrast, a family deductible is the most a family must pay before cost-sharing kicks in for everyone.
π Where this applies: Every state Vivna serves
β Do I have to meet my deductible before preventive care is covered?
Usually not, since most plans cover in-network preventive care at 100% before you meet the deductible.
In fact, some plans even waive the deductible for other covered services.
π Where this applies: Every state Vivna serves
β What is coinsurance?
Coinsurance is your share of a covered cost after you meet your deductible.
You and your plan each pay a percentage that adds up to 100%. For example, the plan pays 80% and you pay 20%.
π Where this applies: Every state Vivna serves
β What is a copay?
A copay is a flat fee you pay each time you see your doctor or fill a prescription.
You can find the amount on your health plan ID card.
π Where this applies: Every state Vivna serves
β What is the difference between a copay and coinsurance?
A copay is a set dollar amount you pay at the visit or pharmacy.
By contrast, coinsurance is a percentage of the cost you pay after meeting your deductible.
π Where this applies: Every state Vivna serves
β Do I pay a copay for prescriptions?
Often, yes, a copay can apply when you fill a prescription, not just at doctor visits.
So check your ID card for your copay amounts.
π Where this applies: Every state Vivna serves
β Where can I find my deductible, copay and coinsurance?
You can find them on your health plan ID card.
Your copays appear on it. In addition, most ID cards show your deductible and coinsurance.
π Where this applies: Every state Vivna serves
β What does cost-sharing mean in health insurance?
Cost-sharing is the part of covered costs you pay yourself.
It generally includes deductibles, coinsurance and copays.
π Where this applies: Every state Vivna serves
β What are out-of-pocket costs?
Out-of-pocket costs are medical expenses your insurance does not reimburse.
These include deductibles, coinsurance and copays for covered services. They also include everything you pay for services that are not covered.
π Where this applies: Every state Vivna serves
β What is an out-of-pocket maximum?
An out-of-pocket maximum is the most you would have to pay for covered medical services in a year.
Once you reach it, your plan may then pay 100% of covered services.
π Where this applies: Every state Vivna serves
β Can I lower my out-of-pocket maximum?
If you qualify for cost-sharing reductions, you also get a lower out-of-pocket maximum.
However, those savings only apply on a Silver plan.
π Where this applies: Every state Vivna serves
β Is preventive care free with health insurance?
Preventive care is typically free when you use in-network providers.
That includes an annual check-up, a flu shot, kids' vaccines and certain wellness screenings.
π Where this applies: Every state Vivna serves
β Are travel vaccines covered as preventive care?
Not always, because preventive coverage varies by plan.
In fact, some plans do not cover most travel immunizations. Check the plan documents for the list of covered preventive services.
π Where this applies: Every state Vivna serves
β What is a health insurance claim?
A claim is a request for payment sent to your health insurer.
You or your provider submit it when you get items or services you think are covered.
π Where this applies: Every state Vivna serves
Metal Levels and Choosing a Plan
Bronze, Silver, Gold and Platinum plans split costs differently. Here you can see which level fits your needs.
β What are the metal levels on ACA plans?
Marketplace plans come in four levels: Bronze, Silver, Gold and Platinum.
Each level reflects how you and your plan split the costs of care.
π Where this applies: Every state Vivna serves
β Does a higher metal level mean better quality care?
No, metal levels have nothing to do with the quality of care.
Instead, they only show how you and the plan split costs.
π Where this applies: Every state Vivna serves
β What costs are included when comparing metal levels?
Each metal level means you pay a different share of total yearly costs.
Total costs include premiums, deductibles, and out-of-pocket costs like copays and coinsurance.
π Where this applies: Every state Vivna serves
β What is a Bronze health plan?
Bronze plans usually have the lowest monthly premiums but the highest costs when you get care.
Also, their deductibles can be very high.
π Where this applies: Every state Vivna serves
β What is the downside of a Bronze plan?
The downside is that Bronze deductibles can be very high.
So you could pay thousands of dollars in care costs yourself before the plan starts paying its share.
π Where this applies: Every state Vivna serves
β What is a Silver health plan?
Silver plans fall in the middle, with moderate monthly premiums and moderate costs when you need care.
π Where this applies: Every state Vivna serves
β Why do so many people choose Silver plans?
Silver plans are the most common choice of Marketplace shoppers.
In addition, if you qualify for cost-sharing reductions, you only get those savings on a Silver plan.
π Where this applies: Every state Vivna serves
β What is a Gold health plan?
Gold plans usually have higher monthly premiums but lower costs when you get care.
So they may fit people who use a lot of medical services.
π Where this applies: Every state Vivna serves
β Who is a Gold plan a good fit for?
Gold may be a good choice if you use a lot of medical care.
It also fits people who would rather pay more up front and less when they get care.
π Where this applies: Every state Vivna serves
β What is a Platinum health plan?
Platinum plans usually have the highest monthly premiums of any level.
In return, however, they pay the most when you get medical care.
π Where this applies: Every state Vivna serves
β When does a high-deductible health plan make sense?
A high-deductible plan may fit a healthy family that needs little more than preventive care.
You pay a lower premium. However, it may take longer to meet your deductible.
π Where this applies: Every state Vivna serves
β When does a low-deductible health plan make sense?
It may fit you if you are older, have a chronic condition, are pregnant or need expensive prescriptions.
You pay a higher premium. However, you meet your deductible sooner.
π Where this applies: Every state Vivna serves
β What are Marketplace quality star ratings?
These ratings score health plan quality from 1 to 5 stars on Marketplace plan pages.
In addition, each plan gets an overall rating.
π Where this applies: Every state Vivna serves
β What goes into a plan's overall quality rating?
A plan's overall rating draws on three areas: member experience, medical care and plan administration.
π Where this applies: Every state Vivna serves
Open Enrollment and Special Enrollment
These answers cover when you can enroll and which life events open a special window. Also, see where to buy a plan.
β Where can I buy an individual health insurance plan?
You can buy through a state or federal health exchange.
Plus, you can enroll with a licensed broker like Vivna, or directly with an insurance company.
π Where this applies: Every state Vivna serves
β What is the Health Insurance Marketplace?
The Marketplace, also called the exchange, helps people shop for and enroll in ACA health plans.
It also offers help through websites, call centers and in-person assistance.
π Where this applies: Every state Vivna serves
β Is HealthCare.gov the Marketplace for every state?
No, the federal government runs HealthCare.gov for most states, not all of them.
However, some states run their own Marketplaces.
π Where this applies: Every state Vivna serves
β Can I get in-person help enrolling in a Marketplace plan?
Yes, the Marketplace offers in-person help, plus help through websites and call centers.
Licensed agents and brokers can also help you enroll.
π Where this applies: Every state Vivna serves
β What is Open Enrollment for health insurance?
Open Enrollment is the yearly period in the fall when you can enroll in a health plan.
Coverage you pick then is for the next calendar year.
π Where this applies: Every state Vivna serves
β Can I get health insurance after Open Enrollment ends?
Yes, you can if you qualify for a Special Enrollment Period.
That lets you enroll in a Marketplace plan for the current plan year.
π Where this applies: Every state Vivna serves
β What is a Special Enrollment Period (SEP)?
An SEP lets you enroll in a Marketplace plan outside Open Enrollment.
You qualify after certain life events, for example getting married, having a baby or losing coverage.
π Where this applies: Every state Vivna serves
β What is a qualifying life event?
A qualifying life event is a change in your situation that can open a Special Enrollment Period.
For example, getting married, having a baby or losing health coverage can count.
π Where this applies: Every state Vivna serves
β Does losing my job-based health insurance let me enroll outside Open Enrollment?
Yes, losing existing health coverage, including job-based coverage, is a qualifying life event.
As a result, it can open a Special Enrollment Period.
π Where this applies: Every state Vivna serves
β If my individual health plan is discontinued, can I get a Special Enrollment Period?
Losing existing coverage, including an individual plan, is a qualifying life event.
That said, a licensed Vivna agent can help confirm your options and timing.
π Where this applies: Every state Vivna serves
β Does losing a student health plan qualify me for special enrollment?
Yes, losing a student plan is a listed loss of coverage that counts as a qualifying life event.
π Where this applies: Every state Vivna serves
β Does losing Medicaid or CHIP let me enroll in a Marketplace plan?
Yes, losing eligibility for Medicaid, CHIP or Medicare is a qualifying life event.
So it can open a Special Enrollment Period.
π Where this applies: Every state Vivna serves
β Does getting married or divorced let me change health plans?
Yes, getting married or divorced is a household change that counts as a qualifying life event.
π Where this applies: Every state Vivna serves
β Can I enroll in health insurance after having a baby or adopting?
Yes, having a baby or adopting a child is a qualifying life event.
As a result, it can open a Special Enrollment Period.
π Where this applies: Every state Vivna serves
β Is a death in the family a qualifying life event?
Yes, a death in the family is a household change that can qualify you for special enrollment.
π Where this applies: Every state Vivna serves
β Does moving let me get new health insurance outside Open Enrollment?
It can, because moving to a different ZIP code or county is a qualifying life event.
π Where this applies: Every state Vivna serves
β Does a change in income count as a qualifying life event?
It can, if the change in income affects the coverage you qualify for.
π Where this applies: Every state Vivna serves
β What other life events can qualify me for special enrollment?
Becoming a U.S. citizen or leaving jail or prison can qualify you.
Also, joining a federally recognized Native American nation or becoming an ANCSA Corporation shareholder can qualify.
π Where this applies: Every state Vivna serves
β Is there a complete list of qualifying life events?
No, the common lists of qualifying life events are not complete.
Common examples include loss of coverage, household changes, moving and income changes. So ask a licensed agent about your situation.
π Where this applies: Every state Vivna serves
Premium Tax Credits and Extra Savings
Financial help can lower your premium and your costs at the doctor. So see who qualifies and how it works.
β What kinds of financial help are available for ACA plans?
There are two types of federal financial help: premium tax credits and cost-sharing reductions.
Both help make health insurance more affordable for people who qualify.
π Where this applies: Every state Vivna serves
β How do I find out if I qualify for health insurance subsidies?
A Marketplace application shows whether you qualify for premium tax credits and extra savings.
So fill out a Marketplace application to find out. A licensed Vivna agent can also help you apply.
π Where this applies: Every state Vivna serves
β What is a cost-sharing reduction (CSR)?
A CSR is a discount that lowers what you pay for deductibles, copays and coinsurance.
In fact, the Marketplace often calls it extra savings.
π Where this applies: Every state Vivna serves
β What are extra savings on the Health Insurance Marketplace?
Extra savings is the Marketplace name for cost-sharing reductions.
They lower your deductibles, copays and coinsurance if you qualify.
π Where this applies: Every state Vivna serves
β Do I have to pick a Silver plan to get cost-sharing reductions?
Yes, if you qualify for extra savings, you only get them on a Silver plan.
In fact, they can save you a lot on deductibles, copays and coinsurance.
π Where this applies: Every state Vivna serves
β Can tribal members get extra help with health insurance costs?
Yes, members of federally recognized Native American nations may qualify for additional cost-sharing reductions.
ANCSA Corporation shareholders may qualify as well.
π Where this applies: Every state Vivna serves
Networks, Doctors and Prescriptions
Staying in-network keeps costs down. In addition, these answers explain PCPs and generic drugs.
β What is a health plan network?
A network is the group of facilities, providers and suppliers your plan has contracted with.
These are the places your plan expects you to use for care.
π Where this applies: Every state Vivna serves
β What is an in-network provider?
An in-network provider has a contract with your health plan to give you services at a discount.
As a result, staying in-network usually means lower costs for you.
π Where this applies: Every state Vivna serves
β Why does staying in-network save me money?
Network providers agree to give lower rates to the plan's members.
As a result, your share of the bill stays lower.
π Where this applies: Every state Vivna serves
β How do I check if my doctor is in a plan's network?
Search the insurance company's online provider directory for your doctor, dentist or hospital.
A licensed Vivna agent can also help you check before you enroll.
π Where this applies: Every state Vivna serves
β What is a primary care provider (PCP)?
A PCP is the provider who gives, coordinates or helps you access a range of health care services.
It can be an M.D., D.O., nurse practitioner, clinical nurse specialist or physician assistant, as state law allows.
π Where this applies: Every state Vivna serves
β Do out-of-network balance bills count toward my cost-sharing?
No, balance billing amounts from non-network providers are not part of cost-sharing.
So using in-network providers helps you avoid them.
π Where this applies: Every state Vivna serves
β What is a generic drug?
A generic drug has the same active-ingredient formula as a brand-name drug.
Plus, generics usually cost less than brand-name drugs.
π Where this applies: Every state Vivna serves
β Are generic drugs as safe as brand-name drugs?
Yes, the FDA rates generic drugs to be as safe and effective as brand-name drugs.
Plus, they usually cost less.
π Where this applies: Every state Vivna serves
Agents, Brokers and Community Help
A licensed broker can help you enroll at no extra cost. Here you can see how agents work and where to find more help.
β What does a health insurance agent or broker do?
An agent or broker is a trained insurance professional who can help you enroll in a health plan.
Vivna Insurance, for example, is a licensed broker.
π Where this applies: Every state Vivna serves
β What is the difference between an insurance agent and a broker?
Agents may work for a single health insurance company, while brokers may represent several.
π Where this applies: Every state Vivna serves
β Does it cost more to enroll through a health insurance broker?
No, you will not pay anything extra if you enroll with a licensed agent or broker.
π Where this applies: Every state Vivna serves
β How do health insurance agents and brokers get paid?
Agents and brokers often get commissions from insurance companies for selling plans.
However, some may not sell plans from companies they do not represent.
π Where this applies: Every state Vivna serves
β Where can I find free help with food, rent or utilities near me?
You can search for local resources at no cost at Cignaresources.findhelp.com.
The site lists help for basic needs near you.
π Where this applies: Every state Vivna serves
ICHRA and Employer-Funded Individual Plans
An ICHRA lets an employer fund your individual plan. These answers explain how premiums and enrollment work.
β What is an ICHRA?
An ICHRA is an employer health benefit where employees enroll in individual health plans.
Then premiums come out of employer funds held in the employee's virtual account on an ICHRA platform.
π Where this applies: Every state Vivna serves
β Can an ICHRA plan be bought on or off the exchange?
ICHRA enrollments can involve on-exchange or off-exchange individual plans.
However, picking the wrong type takes extra steps to fix. So confirm which type your employer's ICHRA uses before enrolling.
π Where this applies: Every state Vivna serves
β Who makes sure there is money in my ICHRA to pay my premium?
The ICHRA platform is responsible for making sure funds are in your virtual account before each premium draft.
Otherwise, short funds can cause a failed payment, fees, or coverage loss.
π Where this applies: Every state Vivna serves
β What if I enrolled in the wrong exchange type for my ICHRA plan?
The wrong plan has to end before the new one can start.
That's because overlapping coverage is not allowed, so the old plan needs an end date first.
π Where this applies: Every state Vivna serves
β How do I cancel an individual plan I bought on the Marketplace?
Call the Marketplace or state-based exchange where you first applied.
That's because they handle terminations for on-exchange plans.
π Where this applies: Every state Vivna serves
π More Health Insurance Guides
These answers cover the basics in short form. When you want more depth, these guides from our licensed agents walk through costs, plan types and enrollment. Then, if a question comes up, call 888-730-6001 anytime.
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π Questions About Health Insurance?
These answers cover the most common health insurance questions, but every family is different. Therefore, our licensed agents compare plans and check subsidies for free.
Best of all, our help costs you nothing. Request a free quote online, or call 888-730-6001 to speak with an agent today. You can also reach us through our contact page.
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Official resources: the Centers for Medicare and Medicaid Services, HealthCare.gov, and the National Association of Insurance Commissioners.
Vivna Insurance is an independent, licensed agency appointed with 50+ carriers nationwide. Plans, benefits and availability vary by state.