Non-Medicare / Insurance Marketplace

The information on MSAA’s My Health Insurance Guide has been divided into two main categories, non-Medicare insurance and Medicare Insurance. In this section on non-Medicare insurance, details are presented on employer-based and private insurance, Medicaid, and the Insurance Marketplace. Also found in this section is information on different types of appeals (including both Marketplace appeals and Medicaid or private insurance appeals).

The section titled PLAN ahead may be of particular interest to anyone looking for new insurance or making a change from their existing plan. MSAA recognizes that selecting a healthcare-insurance plan can be confusing and, at times, overwhelming. To help lessen confusion and better prepare people for this important decision, MSAA has created a simple acronym that identifies key areas to consider when planning health-insurance coverage. Prior to making an insurance selection, we encourage individuals to PLAN ahead (Prepare, Look, Analyze, and Name).

Please be sure to also visit the resources listed under “Additional Information.” These include MSAA’s Healthcare Insurance Glossary, a listing of resources, MSAA’s online insurance webinars and video, as well as our insurance publications.

Before you begin learning about the Insurance Marketplace, please review the following list of very important insurance terms that will help you navigate and better understand how to select a policy that meets your needs.

Important Terms

Co-insurance – Your share of the costs of a covered healthcare service, calculated as a percent (for example, 20 percent), after you have met your deductible. For example, if the health insurance plans allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20 percent would be $20. The health insurance pays the balance of the allowed amount.

Co-pay – A pre-determined amount (for example, $20) that you pay for a covered healthcare service, usually at the time of the service. The amount can vary by the type of covered healthcare service.

Deductible – Out-of-pocket healthcare costs for which individuals are responsible, before their health insurance plan will pay for health expenses.

Formulary – A list of prescription medications your insurance provider will cover.

Marketplace/Exchange – Forum in which individuals and businesses can compare, choose, and purchase healthcare insurance plans.

Out-of-pocket limit (maximum) -The total amount that needs to be paid by an individual before the health-insurance plan provides 100 percent in coverage for medically necessary costs.

Premium – Amount of money charged by the insurance company for coverage. It may be paid in a lump sum or periodic monthly payments, dependent upon the insurance plan.

Step Therapy – When a prescription-drug plan requires an individual to try one or more other, lower-cost medications before covering the prescribed drug.

For an expanded list of insurance terms, please go to MSAA’s Healthcare Insurance Glossary.