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Do you ever feel like health insurance is a foreign language? If you do, we understand, and we’re here to tell you that you’re not alone.

According to this recent survey, 26% of Americans avoided care or treatment because they were unsure what their insurance covered. Having health insurance literacy is important because the more you know, the better off you are when it comes to using your coverage and getting the medical care you need.

Below we explain the most commonly used health insurance terms and answer frequently asked questions.

1. Premium
2. Co-payment
3. Deductible
4. Out-of-Pocket Maximum/Limit
5. Copay
6. Co-insurance
7. In-Network
8. Covered Services
9. Excluded Services
10. Open Enrollment Period
11. Special Enrollment Period
12. Subsidy
13. Tax credit
14. Health Insurance Marketplace
15. Essential Health Benefits
16. Short-Term Health Plan
17. Schedule of Benefits
18. Frequently Asked Questions

What should I know?

There’s a lot to take in, but we’re not trying to confuse you. So, we’ve narrowed it down to what’s most important for understanding your plan. By the end of this, you should feel like a health insurance expert!

Premium
The total amount the insured pays each month for health coverage.

Co-Payment
A fixed amount the insured pays out-of-pocket for covered medical services, with the remaining balance covered by the insurance company.

Deductible
A fixed amount the insured pays before the insurance company will pay for any covered services.

Out-of-Pocket Maximum/Limit
The total amount the insured pays out-of-pocket for covered services in a plan year. When the limit is met, the health plan pays 100% of the costs for the remainder of the plan year.

Co-Pay
The fixed rate that the insured pays after the deductible has been met.

Coinsurance
The percentage that the insured pays after the deductible has been met. For example: If the insured has 80/20 coinsurance, the insured pays 20% for covered services while the insurance company pays the remaining 80%.

In-Network
A provider or health care facility that is part of a health plan’s network in which covered services are provided at discounted rates.

Covered Services
These are services that your health insurance plan has agreed to pay, also known as your plan benefits.

Excluded Services
These are services that your health insurance plan does not pay for or cover.

Open Enrollment Period
The yearly period when people can enroll in a new health plan or switch to a different plan. Typically, Open Enrollment runs from November 1 to December 15, and plans are effective January 1.

Special Enrollment Period
The time outside of Open Enrollment when people can enroll in a health plan if they have a qualifying life event. If a person qualifies for a SEP, they typically have up to 60 days following the event to enroll.

Subsidy
Financial assistance from the government that helps pay for health insurance. Eligibility depends on household income, family size, and zip code.

Tax credit
A credit that helps reduce a family or individuals’ monthly payment and are only available to those who are enrolled in a plan through the federal insurance marketplace.

Health Insurance Marketplace
Also known as the “Marketplace” or “exchange”, is a service that helps people find an affordable health plan and is run by the federal government, for most states. Every health plan available covers a set of essential health benefits.

Essential Health Benefits
Every health insurance plan available on the Marketplace must cover a set of 10 categories of services.

• Doctor’s services
• Preventative and wellness services
• Inpatient and outpatient hospital care
• Prescription drug coverage
• Pregnancy and childbirth
• Pediatric services, including oral and vision care
• Laboratory services
• Emergency services
• Mental health services
• Rehabilitative and habilitative services and devices

Short-Term Health Plan
A health plan with a limited duration, typically a few months to a year, used to bridge the gap between coverage.

Schedule of Benefits
A document that outlines the various services covered under a health plan, along with the fees associated with each service and treatment.

FAQ’s

How do I know what my plan covers?
Reference your Schedule of Benefits for all services and treatments covered by your health insurance plan. You can also contact the insurance company, or your agent, to request a copy.

How does my deductible affect my premium?
Premium costs vary but plans with a lower deductible tend to have a higher monthly premium than those with a higher deductible.

What’s the difference between in-network and out-of-network providers?
In-network providers or health care facilities are part of a health plan’s network of providers and provide services at a discount negotiated with the insurance company. Out-of-network providers or facilities don’t have a contract with the health insurance company; therefore, no discount is provided on covered services. Health care services are significantly lower with an in-network provider.

What is considered a Qualifying Life Event?
A change in your situation can make you eligible for a Special Enrollment Period, allowing you to enroll in or change plans outside of Open Enrollment. You may qualify if you experience one of the following life events in the last 60 days.

• Got married
• Had a baby
• Got divorced or separated and lost coverage
• Moved to a new zip code or county
• Loss of health insurance, individual and job-based

Important: You do not qualify for a Special Enrollment Period if you voluntarily drop coverage or don’t pay your premium.

Go to Healthcare.gov to see a complete list of Qualifying Life Events.

When is Open Enrollment?
The Open Enrollment period is typically from November 1 until December 15 to enroll in a health plan through the Marketplace. All plans are effective January 1.

Can I get insurance outside of Open Enrollment?
Yes. You may qualify for a Special Enrollment Period (SEP) if you have a certain life event. If you do not qualify, there are other plans available that will bridge the gap until the next Open Enrollment period.

Should I go uninsured?
No, we really don’t suggest it. Making health a priority for you and your family is one of the best ways of protecting them and showing you care.

How do I enroll in a health plan?
That’s simple! Call LEB Insurance Group at 920.214.5320 or request a quote online. We’ll connect you with one of our licensed agents to help find a plan that best fits your needs.

Looking for personalized insurance solutions?
Our preferred licensed health insurance agency has over 270 licensed agents nationwide. They offer health insurance, life insurance, supplemental coverage, and financial services. Request a Free Quote from them right here at zerohealthinsurancebill.com and then discover how to Zero your monthly health insurance bill.

What is Group Health Insurance?

Group health insurance is a policy purchased by a company to offer to their employees as one of the benefits of employment. Group health insurance can also be offered by professional associations, trade groups, and unions to their members. These plans cannot be purchased by individuals. The employer or administration typically pays for, or “sponsors,” a portion of the insurance premium.

An employer may choose to offer a single plan option or tiered plans ranging from basic coverage to more robust coverage with add-ons. The employer may also extend coverage to the employee’s immediate family. Companies with over 50 full-time equivalent employees are federally mandated to offer affordable minimal essential health insurance coverage, but many smaller companies offer it as well.

Who is Eligible for Group Health Insurance?

The following may be eligible for coverage under an employer’s group health plan:

Full-time employees: Those who work at least 30 hours per week are considered full-time and are eligible if the employer offers health insurance coverage. The employer may require a waiting period for new employees before they can enroll.

Part-time employees: Some employers extend coverage to their part-time workforce, based on other eligibility criteria including hours worked.

Spouses: The employee’s husband or wife is allowed coverage under their plan. Some employers may require documentation, such as a marriage certificate. Usually, it doesn’t matter whether or not they are claimed as a tax dependent.

Domestic partners: Many employers now extend eligibility to non-married partners who reside with the covered employee. Additional requirements may apply.

Children under age 26: Dependent children of a covered employee must be offered coverage under the employee’s plan. Adult children under age 26 are also eligible for inclusion, even if they are not tax dependents or don’t live with their parents.

Dependent adults: An adult family member (such as an elderly parent or special-needs relative) who is financially dependent on a covered employee may be eligible under certain circumstances.

Former employees: For a limited time (usually up to 18 months) after leaving a company, COBRA plans allow former employees to keep their existing group plan, but they must bear the full premium cost. Some employers even extend group insurance eligibility to retirees.

It’s important to note that while the employer may pay for some or all of the premium for the enrolled employee, there is no legal requirement to pay the premium for family members.

What are the Advantages of Group Health Insurance for Employers and Employees?

Group health insurance is the most familiar way to provide protection for employed individuals and their families, and it offers many incentives for both employers and employees.

Advantages for Employers

1. Attracting and retaining quality employees
2. Ensured wellness of your workforce with fewer sick days
3. Increased productivity
4. Business tax deductions
5. Compliance with federal law

Advantages for Employees

1. Improved job satisfaction
2. Affordable healthcare
3. Large networks with comprehensive coverage
4. Premiums paid pre-tax, reducing taxable income

Group insurance plans are typically more affordable than individual plans, because the premium costs are subsidized by the employer and the claims risk is shared among all members in the group’s plan. Choosing a plan with a high deductible and low premium further helps minimize the monthly expense.

Various plans are available to best meet the needs of the employee and his or her family, such as HMO plans, PPO plans, and high-deductible plans. Healthcare options are robust, often with large provider networks and uncapped visits to in-network specialists. Additionally, some employers offer benefits such as dental plans, vision plans, and Health Savings Account contributions.

Who Pays for Group Health Insurance?

Group health insurance plans allow the cost to be split between the employer and all employees under the plan. Here are the possible scenarios:

1. The employer pays the entire premium for the employee.
2. The employee pays a portion of the premium, while the employer pays the rest.

Before enrolling in a health plan, an employee can check with their employer or HR department to calculate what the employer contribution and employee responsibility amounts will be.

How Do I Compare Different Plans Offered?

When comparing health plan options, consider the premiums (monthly payment), deductibles (the amount you pay before your insurance applies), and copays (the amount you pay for services). You should also compare coverage offered for prescriptions, mental health care, and other services that apply to you.

Finally, make sure that the providers in the network fit your needs. Are they located nearby? Do they have appointments available when you need them? Do they offer the services you need? If you already have a doctor you like, verify that they are in your plan’s network.

Group Health Plans vs. Individual Health Plans

Group health plans offer some benefits that are not available with an individual health plan, such as low-cost premiums and smaller deductibles. However, while group plans are usually more cost-effective, they can limit those on the plan to using certain providers and have less flexibility for coverage.

Everyone should weigh the pros and cons when deciding whether to enroll in their employer’s group plan or to look elsewhere for health coverage. For those who cannot get group health insurance, they can purchase an individual health plan instead.

How We Can Help

If you’re like most employers, you want to offer the best healthcare options for your employees and yourself. Whether it’s a desire to be a workplace hero or just to make everyone healthier, we’re here to help. It’s quick and easy to get a group health insurance quote online. Our preferred licensed insurance agent have plans that are tailored for groups of all sizes, and can suggest the right plan for your company.

Here’s how our preferred licensed insurance agent can provide better benefits for your employees:

1. Multiple carriers to choose from
2. Real-person contact for all questions
3. Personalized employee benefit booklets
4. Quick and easy enrollment with your company’s own enrollment website
5. Dedicated broker and advocate on your side

Request a Free Quote from them right here at zerohealthinsurancebill.com and then discover how to Zero your monthly health insurance bill.

Owning a small business comes with both challenges and great rewards. While navigating the options for healthcare coverage may be one of those challenges, there are many health insurance options available to small business owners that can help them save money and maintain good health.

Options for Health Coverage

While employed counterparts can rely on their employers’ group plans, self-employed individuals must look to alternatives. In the absence of an employer-sponsored plan, anyone seeking health insurance coverage must obtain an individual health plan. Individual plans can be obtained independently at any time.

In addition, affordable plans through the Health Insurance Marketplace are common for self-employed business owners. While enrolling in a Marketplace plan is normally limited to the annual Open Enrollment period, experiencing a scenario known as a Qualifying Life Event (QLE) allows an individual to enroll outside of Open Enrollment. Qualifying Life Events include getting married, having a baby, relocating, or losing existing health coverage (even as a result of leaving employment where health insurance was offered). Marketplace plans offer a subsidy for those under a certain income level, making these plans potentially even more affordable– a welcome option for those in the start-up phase of their business.

Depending on various eligibility factors, small business owners may also have the option to enroll in a group health plan with their spouse, domestic partner, or parents, if these individuals have health coverage through an employer or other source. Group insurance plans often have affordable premiums, making this a cost-effective option.

Are Health Insurance Costs Tax-Deductible?

Like other business expenses, health insurance premiums can be a tax deduction. This helps alleviate some of the financial burden of entrepreneurship.

• Sole proprietors and single-member LLCs: Those who file their taxes on a Schedule C can claim the self-employed health insurance deduction on Form 1040, reducing their taxable income by the amount paid for health insurance premiums.
• Partnerships and S-Corps: While health insurance premiums generally are not deductible expenses on the business’s tax return, they can be deducted on the partners’ or shareholders’ personal tax returns.
• C-Corporations: Health insurance premiums paid by a corporation for its employees is an allowable business tax deduction.

Note that in any of these scenarios, the monthly premium payment can be deducted, but not the costs for healthcare services.

It’s important to consult with a qualified tax professional for guidance regarding business tax deductions. Tax laws may change year-to-year, and other scenarios can affect what deductions are allowed.

The Importance of Health Coverage for Entrepreneurs

Many small business owners overlook the importance of health insurance due to other financial obligations of running their own business. However, getting coverage is crucial for various reasons:

• Protection for health: Health insurance provides coverage for medical expenses, including preventive care, illnesses, accidents, and medical emergencies. This coverage ensures that self-employed individuals can access necessary healthcare without worrying about unexpected and extreme costs.
• Reducing risk on business operations and ensuring sustainability: Health issues can arise unexpectedly and might not only affect personal well-being but also cause strain on the sustainability of the small business. Health insurance allows business owners to mitigate the financial risks associated with sudden health problems, reducing the impact on their business operations. This allows them to focus more on building their business and less on worrying about a potentially large financial burden.
• Attracting new talent and compliance with laws: For those small business owners who have employees or who are considering hiring employees, offering health insurance can help attract and retain better talent. In addition, depending on the number of employees and state laws and regulations, a business owner might be legally required to offer a group insurance plan.

Health insurance coverage is an investment that serves as a safety net, protecting both the entrepreneur and their business from unexpected health-related financial challenges.

How to Enroll in a Health Plan

We know how confusing it can be to find your health insurance coverage. The smartest course of action is to enlist the help of a licensed insurance agent to help you enroll in an individual health plan or a Marketplace health plan, so you can focus on your business instead.

Our preferred licensed insurance agent can help you find the most affordable plan for you and your family, with coverage that works best for your needs. Request a Free Quote from them right here at zerohealthinsurancebill.com and then discover how to Zero your monthly health insurance bill.