Georgia Individual Health Insurance Information And Definitions

Before we begin to try to understand the different types of Georgia health insurance, there is a bit of information we need to be familiar with. All insurance plans have certain things in common. It would be helpful to understand what they are so you can see how they apply to each type of insurance.



Tax Credit: The premium tax credit is a refundable tax credit designed to help eligible individuals and families with low or moderate income afford health insurancepurchased through the Health Insurance Marketplace, also known as the Exchange, beginning in 2014. This may also be called a Subsidy.


Cost Share Reduction: Along with tax credits, you may recieve something called a cost share reduction. This lowers the deductible, Out of pocket, copays, etc. on silver level plans sold on the marketplace depending on your income. 


Deductible-This is the portion of any health charges that you pay before the insurance company pays anything (many plans waive the deductible for physician office visits, instead using an office visit co-pay). ALL plans have a deductible. It may be vary form $0 to $10,000, but it's always included in the plan benefits.


Coinsurance- After the deductible is met, you enter into a period of coinsurance. It's just what the name says. Two entities are paying the health costs during the coinsurance period. When you see the term 80/60 it means that if you stay in network, you pay 20% and the insurance company pays 80% of the charges. Out of network, you pay 40% and the insurance company pays 60%. There is normally a stop loss of $1000 or more that the insured has to pay. In other words, if your plan reads 80/20 through $5000, you would be responsible for 20% of $5000 after the deductible has been met. Then the insured's liability would stop and the insurance company would pay the rest.


**Not all plans have coinsurance. Often, you won't find coinsurance in an HMO or POS plan, and often it won't be in an HSA eligible plan.

After the deductible and coinsurance have been met, the insurance company has the liability of any other covered health charges during the plan year.


Max Out of Pocket- The total out of pocket in a year that you will pay for covered services.


Short Term Medical Plan: Designed for the healthy, short-term policies originally served to provide an affordable option to cover gaps in coverage. Their terms allow for 3 months of coverage, and most allow you to reapply after the 3 months. 


Indemnity Plan: Allow you to direct your own health care and visit almost any doctor or hospital you like. The insurance company then pays a set portion of your total charges. (Indemnity plans are also referred to as "fee-for-service" plans.)


There are 2 more terms you should be familiar with:


NETWORK - A group of providers, doctors, hospitals, labs, etc. that have a relationship with the insurance company and have established specific pricing for services. This is the way that insurance companies manage their costs.


OUT OF NETWORK - An out of network provider is any physician, hospital, lab, etc. who does not participate (or "accept") your insurance plan. In the event that you utilize one of these providers, your "out of network" benefit would apply, if your plan includes an out of network benefit. Your out of pocket costs and deductibles are usually higher when utilizing this benefit. This benefit is also known as a type of Indemnity benefit.






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