Medical cost-sharing FAQs: Beyond the basics

If you want to purchase health insurance share plans, then you have reached the right place. This post discusses some of the least popular topics of healthcare-sharing insurance plans. This information may be very useful if you plan to enroll in healthshare insurance to help you make the right choices.

 

What will happen in case an enrollee gets care from an out-of-network provider?

 

In this case, the enrollee has to pay more in total deductibles, copayments, and coinsurance. This amount will exceed the out-of-pocket limit since it does not apply to cost-sharing charges related to out-of-network healthcare services. This is one of the important things to be discussed with your provider when you purchase health insurance share plans.

 

What happens if an enrollee gets medical care service that the healthshare plan does not cover?

 

In this case, the medical sharing plan will not cover any charges. Hence, the person has to pay all of the costs out of pocket, and this amount will not be subjected to the health's laws out-of-pocket maximum. The same will apply even if the enrolled gets healthcare service that is not covered in the plan from an in-network provider. 

 

Are you required to spend the full out-of-pocket maximum limit each year?

The straight answer to this is a plain no. In most cases, the medical expenses spent by the enrollee may not reach the out-of-pocket limit. But the limit will provide critical financial protection for those with serious illness or injury, especially for unexpected health care needs. If a person who has a healthshare plan has to visit a physician only once a year and fills only one prescription, they might have to spend only a little out-of-pocket cost in one year. This will depend on the charges for the care received and the coverage details. However, it is an illness that requires expensive treatment, hospitalization, copayments, coinsurance, and total deductible; it could reach hundreds of dollars if there were no out-of-pocket maximum limit set.

 

Who will pay for the healthcare after the out-of-pocket limit is reached?

 

Suppose a person reaches their total out-of-pocket maximum limit regarding copayments, deductibles, and coinsurance for in-network and covered benefits. In that case, the healthshare plan will pay the full costs for any covered medical care services that the person receives from in-network healthcare providers. 

 

Are there other standards related to cost-sharing charges additional to the out-of-pocket maximum?

 

Most health insurance companies are organized into coverage levels or tiers named after precious metals like gold, silver, bronze, and platinum. These plans are categorized into groups based on their actuarial value, which estimates and compares the overall generosity of different plans. The plan's actuarial value will increase as the preciousness of the metal increases, thus lowering the cost-sharing charges. This means that gold will have a higher actuarial value and lower cost-sharing charges than silver. Therefore the plan will pay a larger share of costs when the enrollee uses medical services.

 

Are the healthcare-sharing plans offered by organizations other than health insurance companies, like employers, affected by cost-sharing requirements?

 

Under the Affordable Care Act, the out-of-pocket maximum generally applies to employer and individual health insurance plans. But the requirements for exchange plans in metal tiers only apply to individual and small-group insurance companies. These do not apply to the medical cost-sharing programs offered by large employers.

 

Do all healthshare plans offered by insurance companies have to be in a metal tier?

 

Health insurance companies offer health share plans that must fit either within one of the metal tiers or be a catastrophic plan created as an option for young people. These plans have a very high deductible, meaning enrollees must pay the full cost of any medical care service they might need until they spend $9,100. Hence, these plans are not eligible for purchase with premium tax credits. But there is an exemption for preventative services provided without any cost-sharing charges and when at least three physician visits per year. These plans are mostly taken by people who want to pay a premium as low as possible, those who are not eligible for premium tax credits, and who do not expect to need much health care. Thus, catastrophic plans are mostly enrolled by people under 30. But they are only eligible to enroll in the program if they qualify for the insurance company coverage exemption due to a lack of access to affordable coverage or have experienced hardship. 

 

Why are metal tiers used?

 

Organizing the plans into metal tiers based on the coverage level helps the enrollees compare the different plan options and decide which one would be best for them. It also ensures that there is a basic level of coverage available. Health insurance providers must offer at least gold and silver plans.

 

Bottom line

 

With this post, we now know some of the least talked about aspects of healthcare cost-sharing plans. Make sure that you discuss these factors with your provider before enrolling.