To shop smart for health insurance, it pays to untangle the jargon

Laveta Brigham

Do you know the ACA from your QHP? And how does the FPL fit into the picture? And the MLR? Sorting through the jargon of health insurance can seem like learning a new language, but taking a moment to learn some of it can make a big difference when it […]

Do you know the ACA from your QHP? And how does the FPL fit into the picture? And the MLR?

Sorting through the jargon of health insurance can seem like learning a new language, but taking a moment to learn some of it can make a big difference when it comes to your health and your wallet.

Whether they are insured privately through an employer or through the state insurance marketplace, some people actually buy more insurance than they really need, according to Michael Marchand, chief marketing officer of the Washington Health Benefit Exchange.

Now more than ever, it’s important for consumers to take ownership of their health decisions and make informed choices when comparing plans, says Keith Wallace, a partner in Rice Insurance of Bellingham and Issaquah. Rice is one of about a dozen organizations and brokerages that offer free enrollment assistance to people using the state insurance marketplace.

Open enrollment for 2021 coverage is now through Dec. 15 for coverage beginning Jan. 1. Shop for and compare plans, as well as access in-person, virtual, or online customer support through Washington Healthplanfinder— the health insurance marketplace where individuals, families and small businesses can learn about their health insurance options.

Here is a glossary of 15 things consumers should know about health insurance in order to shop smart.

Affordable Care Act (ACA)— The ACA, commonly known as Obamacare, aimed to make health insurance affordable to all Americans, including millions who had no insurance at all. The act has dramatically reduced the number of uninsured Americans. Among its many stipulations is a requirement that insurance plans cover 10 essential health benefits. Some of the benefits are free; others may have copays. The essential benefits:

  • Doctor visits and hospital stays.
  • Trips to the emergency room.
  • Care before and after your baby is born.
  • Mental health and substance use treatment services.
  • Prescription drugs.
  • Services and devices to help you recover if you get injured, or have a disability or chronic condition.
  • Lab tests.
  • Preventive services including counseling, screenings and vaccination.
  • Management of a chronic disease, like diabetes or asthma.
  • Pediatric care.

Broker or Navigator— A broker or navigator is a person who can help you enroll in a Qualified Health Plan through Washington Healthplanfinder. The greatest difference between the two is that brokers can recommend a specific plan you should enroll in. Brokers are also licensed and regulated by Washington state and typically get payments, or commissions, from health insurers for enrolling a consumer into a plan. Some brokers may only be able to sell plans from specific health insurers.

Coordination of benefits — The process used to decide which insurance plan pays first when two or more plans cover the same individual and are both responsible to pay for a portion of a claim.

Deductible — The amount you will spend on your health care before your health plan starts to pay some of your health care costs. You pay most of your health care costs until you reach the deductible amount. If your plan has a $2,500 deductible, you’ll pay $2,500 of your own money before insurance kicks in and pays for some of your health care costs.

Federal poverty level (FPL)— Federal poverty levels, issued annually by the Department of Health and Human Services, are used to determine eligibility for certain programs and benefits, including Washington Apple Health (Medicaid), health insurance premium tax credits, and cost-sharing reduction subsidies. This year’s poverty level for a one-adult household is $12,760, and your income is typically expressed as a percentage of the federal poverty level. (If your income is $50,040, you make 400% of the FPL.)

Individual mandate — Under the Affordable Care Act, most people must purchase health insurance or pay a tax penalty. This is called the “individual mandate.” However, there are eight types of exemptions to the individual mandate, including members of certain religious groups, American Indians, those below the federal poverty level and noncitizens.

Medicare — Federal health insurance for ages 65 or older and certain younger people with disabilities. Americans apply for Medicare through the Social Security Administration and not through Washington Healthplanfinder. Learn more at ssa.gov/medicare.

Minimum loss ratio — This tenet of the ACA protects consumers by putting a limit on insurers’ profit and overhead. The MLR requires insurers to spend a certain percentage of their premium income (the amount depends on whether they’re in the small or parge group market) on medical and wellness care, as opposed to, say, marketing and operating expenses. Insurers that fall short of that mark must pay back the shortfall to consumers in the form of rebates.

Preexisting condition — A health problem or illness you had before the date that new health coverage starts. Coverage of preexisting conditions is a key pillar of the Affordable Care Act.

Premium tax credits — Premium tax credits are a form of financial assistance that can be used to lower your monthly premium. The amount of the credit depends on the cost of your insurance and your ability to pay it based on your income.

Provider network — A list of all the doctors and other service providers that have signed a contract with your insurance company to provide care for those insured. The contract spells out how much the insurance company will pay for services, as well as your share, if any.

Qualified health plan (QHP)— An insurance plan that has been certified by Washington Healthplanfinder to offer quality insurance. It must provide essential health benefits, follow established limits on cost-sharing (such as deductibles, co-payments, and out-of-pocket maximum amounts), and meet other requirements.

Washington Apple Health — In Washington State, Medicaid is called Apple Health. Apple Health provides preventative care, like cancer screenings, treatment for diabetes and high blood pressure, and many other health care services. You can apply for free or low-cost Apple Health coverage year-round. For most people, Washington Apple Health is free, but some families may have to pay a monthly premium.

Washington Healthplanfinder — The health insurance marketplace where individuals, families and small businesses can learn about their health insurance options and compare plans based on costs, benefits and other important factors. Washington Healthplanfinder also provides information on programs that help people with low-to-moderate incomes and resources pay for coverage.

The Washington Healthplanfinder uses a series of questions to compile a patient profile, then presents shoppers with a handful of prospective plans in an easy-to-compare format.

“People are getting more and more worried about making the wrong choice, and looking at 80 health plans in King County would be extremely hard,” Marchand says. “This is a decision-making tool for them.”

This year, Washington Healthplanfinder will offer a total of 115 Qualified Health Plans and seven Qualified Dental Plans. This includes certification of new Cascade Care products available for the first time on Washington Healthplanfinder.

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