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Individual & Family Health Plans

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How It Works

 

What is a health plan?

A health plan is insurance. It helps protect you financially from the potentially high cost of medical care and puts a cap on the amount you will have to spend.

A serious illness or injury can happen to anyone, at any time. You don’t want to go broke if it happens to you. Think of your health plan as a safety net for your wallet.



What will a health plan do for you?

  1. It will pay for some – but not all – of your medical expenses.
  2. It will cap the amount you could pay for medical services during a year.
  3. It will give you discounts on fees charged by doctors, hospitals and pharmacies.


What happens when you buy a health plan?

When you buy an individual or family health plan:

  1. You pay a fixed monthly premium to your insurance company. It gives you access to a defined set of doctors, clinics and hospitals (network) who will provide the services covered by your plan. Simply by paying your premium, you’ve put a cap on how much it could cost if you get sick or injured, and you’ve avoided a tax penalty. Smart move!

    Premium Policy
  2. You get an insurance policy that describes what’s covered and what’s not covered, and how much of your medical costs you will share with your insurance company if you need to use your benefits.

Factors that help determine your premium include your age, where you live, tobacco use, and family size. Your current or past medical history CANNOT be considered.



How much financial protection will you get?

The amount of financial protection you get from insurance is called coverage. Health insurance does not cover 100 percent of your costs. The amount of coverage you get depends on the type of plan you choose. 

Individual and family plans are available at five different coverage levels. You can choose the coverage level that meets your needs and budget. Here’s what you need to know:

Most health plans available to individuals and families are named for one of these metals: platinum, gold, silver and bronze. A plan’s “metal level” reflects the amount of coverage it provides. Remember, health insurance doesn’t pay for every medical expense. The metal level will tell you about how much of your medical expenses your plan will pay. 

Metal Level The insurer will pay approximately You will pay approximately  Premium
Platinum  90%  10%  $$$$ 
Gold   80%  20%  $$$
Silver   70%  30%  $$
 Bronze  60%  40%  $

Premiums are higher for platinum and gold plans because the insurer covers more of the medical care costs for you and everyone on your plan. Silver and bronze plans have lower premiums, but you will pay more of your own medical expenses.

Metal levels help you compare plans when you’re shopping. A silver plan from Insurance Company A should provide roughly the same amount of coverage as a silver plan from Insurance Company B. 

 

The coverage level below bronze is called catastrophic. Catastrophic plans have the lowest premiums but very high deductibles – $8,550 for an individual in 2021. 
A deductible is the amount you pay for health care services before your plan starts to pay.

Catastrophic plans provide essential protection against the cost of a major illness or injury, and limited help with routine medical expenses. These plans are only available to people under age 30 or those who qualify for a hardship exemption (check out healthcare.gov for more info on hardship exemptions).

Call or visit your state's health insurance marketplace to see if you qualify.



What kind of care is included?

All individual and family health plans help pay for a comprehensive list of health care services called benefits:

  • Most same-day services (office visits, outpatient services)
  • Emergency services
  • Prescription drugs
  • Laboratory services
  • Hospitalization (including surgery and overnight stays)
  • Pregnancy, maternity and newborn care (both before and after birth) 
  • Pediatric services (medical care for children)
  • Rehabilitative and habilitative services and devices (these help people with injuries, disabilities or chronic conditions gain or recover mental and physical skills)
  • Mental health and substance abuse services 
  • Preventive care and chronic disease management
  1. There is no annual limit on the value of services you can receive in these categories as long as you receive them from a provider in your network.

  2. You will generally have to pay a portion of the cost for any service you receive.

  3. The exception is preventive services which are always covered at 100 percent when provided by a network provider. There will be no cost to you for vaccines, screening tests and well-child visits. Many types of contraception are also covered at 100 percent. For more information, check out the Tip Sheet on Preventive Care.

  4. Health plans don’t cover everything. Each plan will have a list of non-covered services or exclusions. Cosmetic surgery and experimental drugs are common examples. Review the policy document for the specific exclusions that apply to your plan.
 

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Need Help?

Call Delta Dental at 1-866-764-5350 (TTY: 711).

Date: 4/17/2021 11:34:12 AM Version: 4.0.30319.42000 Machine Name: PWIM4-CDWEB01