Health insurance can be a complex and confusing topic, but understanding the different options available to you is crucial for making informed decisions about your health care. In this blog post, we will explore some common terms and concepts related to health insurance.
Insurance Plans
High Deductible Health Plan (HDHP)
An HDHP is a type of health insurance plan that has higher deductibles (the amount you have to pay before insurance kicks in) and lower monthly payments compared to other plans.
- HDHPs are typically paired with a Health Savings Account (HSA), which allows individuals to save pre-tax money to pay for qualified medical expenses.
- This can be a great option for those who are generally healthy and don’t anticipate needing frequent medical care.
EXAMPLE: Sarah is generally healthy and only visits the doctor for annual check-ups. She opts for an HDHP with a higher deductible but lower monthly premium. Sarah also opens an HSA, contributing $100 each month. Over the year, she accumulates $1,200 in her HSA, which she uses to cover her annual check-up costs and any unexpected medical expenses. This setup helps her save on monthly premiums while preparing for potential health care costs.
Health Reimbursement Arrangement (HRA)
An HRA is an employer-funded benefit plan that reimburses you for qualified medical expenses.
- Your employer contributes money to the HRA, and you can use those funds to pay for eligible health care expenses.
- HRAs are typically used in conjunction with employer-sponsored health insurance plans and can help offset out-of-pocket costs for employees.
EXAMPLE: John works for a company that offers an HRA. His employer contributes $500 to his HRA annually. John uses this money to pay for his prescription medications and some co-pays for specialist visits. This benefit reduces his out-of-pocket costs for health care, making his overall health care expenses more manageable.
Health Savings Account (HSA)
An HSA is a tax-advantaged savings account that you can use to save money for medical expenses.
- HSAs are typically paired with high-deductible health insurance plans.
- The money you put into your HSA is tax-deductible, which means you don’t have to pay taxes on it.
- You can use the money in your HSA to pay for things like doctor visits or prescriptions. And if you don’t use all the money in your HSA, it rolls over to the next year, so you can save it for future medical expenses.
EXAMPLE: Maria chooses a high-deductible health plan with an HSA. She contributes $200 each month to her HSA, totaling $2,400 annually. Over the year, she doesn’t need much medical care, so she rolls over her savings to the next year. In the following year, she uses her HSA funds to cover the cost of a new treatment not covered by her insurance, demonstrating how HSAs can help build a financial cushion for future health care needs.
Accessing Care
Primary Care Physician (PCP)
Your PCP is the doctor you go to for regular check-ups and general health care needs.
- The PCP is typically a family doctor, internist, or pediatrician, depending on the age and specific needs of the patient.
- Your PCP is responsible for taking care of your overall health, managing any ongoing health problems you might have, and referring you to specialists when necessary.
EXAMPLE: Alex visits his PCP, Dr. Smith, for regular check-ups and general health concerns. When Alex starts experiencing persistent knee pain, Dr. Smith refers him to an orthopedic specialist who provides targeted treatment, while Dr. Smith continues to oversee Alex’s overall health and recovery.
Specialist
A specialist is a health care provider who has advanced training and expertise in a specific area of medicine.
- Examples of specialists include cardiologists, dermatologists, neurologists, orthopedic surgeons, and psychiatrists.
- Patients are typically referred to a specialist by their primary care physician when specialized knowledge or treatment is required for a particular health concern.
EXAMPLE: Emma has been diagnosed with diabetes. Her PCP refers her to an endocrinologist, Dr. Lee who specializes in diabetes management. With Dr. Lee’s expertise, Emma receives personalized treatment plans and advice on managing her condition effectively.
Health Care Systems
Health Maintenance Organization (HMO)
An HMO is a type of plan where you must choose a primary care doctor and get a referral from them to see a specialist. This can be a cost-effective option for those who prefer a more coordinated approach to their health care.
EXAMPLE: David enrolls in an HMO plan and selects a primary care physician. When he needs to see a cardiologist for a heart condition, he first visits his PCP, who provides a referral to the cardiologist within the HMO network. This coordinated care model helps David manage his heart condition with a streamlined approach and potentially lower costs.
Preferred Provider Organization (PPO)
A PPO is a type of plan that gives you more flexibility in choosing your doctors. You can see doctors both inside and outside of the plan’s network, and you don’t need a referral to see a specialist. If you choose an in-network provider, your insurance will typically cover more of the cost, keeping your out-of-pocket costs low. Choosing out-of-network providers may have higher out-of-pocket expenses for you. A PPO is a good option if you want more freedom to choose your health care providers.
EXAMPLE: Lisa has a PPO plan, which allows her to see any doctor she chooses without needing a referral. She wants to see a dermatologist and begins researching providers both inside and outside of her plan’s network. She finds one outside of her network with great reviews that she wants to see. Although she may pay a higher percentage of the cost for out-of-network care, the flexibility of the PPO plan lets her choose the best specialist for her needs.
VEBA Resources
MyVEBA Portal: Use the MyVEBA app or online portal for your benefits information and updates. Download the app for Apple or Android, or visit the MyVEBA Portal for desktop access.
Benefit Contacts: For assistance with specific carrier benefits or issues, such as claims or coverage details, visit vebaonline.com/benefit-contacts to contact them directly.
Get Support: The VEBA Advocacy Team is here to assist with health care navigation, including appointment scheduling and quality of care. Call 888-276-0250 or visit vebaonline.com/contact for assistance. For urgent requests, use the “Urgent” box on the contact form.
If you find this blog helpful in understanding health insurance terms, be sure to check out the other blogs in this series for more in-depth information and insights into the world of health care.
