Do you afford to get ill in America? Quite a tricky question if you are aware of the situations prevailing in health care. Whether you afford it or not you are destined to land in hospital now and then and it requires you to shell a considerable sum to take care of the bills they hand you down. Mind you, if you need to stay there for some days your bill would run tens of thousands of dollars or the amount which might appear astronomical to your budget. Health crisis cannot be predicted so here comes the health insurance to hold you dearly through such distress and pain. Insurance is all about sharing risks. Most insurances are based on the same concepts and follow the similar principle of risk-sharing. You pay a one-time premium to an insurance company so do the other people who go for that insurance plan. As most people instinctively are health conscious and remain healthy, the sum collected through premium is used to take care of the expenses of the insured person getting ill which is relatively small in number in comparison to the number of the person who paid premium. The insurance companies are well acquainted with the risk involved. They aim to garner enough premium to cope with hospital expenses. Different health insurance plans are there in America which cater to various health challenges one has to face accordingly rules and schedules about care vary. What should you ask before buying any health insurance plan so that it manages all of your medical expenses? List of health care providers Where can you get care is the first question you have to seek the answer for before purchasing any health insurance plan. You are very much aware of the procedures one has to undergo while accessing health facilities. It might begin with consulting a doctor and go through different diagnostic tests, scans and end up in complicated invasive surgeries. Insurance companies make a mechanism to lower the cost. They enter into a contract with specified health care providers (Hospitals, Physicians, diagnostic centers, Pharmacies). These health care providers charge less for their services from insurance companies. You have to go through the list of those health care providers carefully before buying the health insurance plan. Look for the presence, access, and credibility of those health care providers in your area. Health insurance companies pay only at their designated health care centers or pay less in case you go for a health care provider which is not on their designated list. Suppose you have bought a family plan and your spouse is living away from you in some different city. She might not be able to get the benefit of that plan in that city. Ingredient of a health care plan What does the plan cover? The affordable care Act has brought considerable clarity to the ingredients of a health care plan. The water was quite muddy before that and in the absence of any clear guidelines assistance offered by different plans has no standards. Now the act specifically direct insurance companies to offer “essential health benefits” Essential health benefits § Emergency services§ Hospitalization§ Laboratory tests§ Maternity and newborn care§ Mental health and substance abuse treatment§ Outpatient care (doctors and other services you receive outside of a hospital)§ Pediatric services, including dental and vision care§ Prescription drugs§ Preventive services (e.g., some immunizations) and management of chronic diseases§ Rehabilitation servicesIngredient of a health care plan The cost of Medicare plan Last but not least is the insurance cost you are going to bear. It is not as simple as it looks. Yes, You pay an upfront premium to buy a health insurance plan. There are some other costs you have to bear yourself to access the health care services they are defined as Deductible, coinsurance, and/ or copays. However, there is no hard and fast rule about it but the most accepted norm is higher is the premium less you have to pay out of your pocket. So the gist of the matter is either you bear the cost at the time of buying or pay it later. Important Insurance Terms and Concepts: § Out of pocket expenses: The amount you pay out of your pocket to get the health care benefits. The monthly premium you pay is separate. " out-of-pocket cost" and/or "cost-sharing" is the term used for the money you are liable to pay when you really receive health care. Health Insurance Terms and Concepts § Annual deductible: The amount you pay every Plan year to receive health care. The health Insurance company starts paying only after you pay the annual deductible. For instance, if the Annual deductible is Rs 1800 $, you have to pay 1800$ before the company starts paying its share of medical expenses § Copayment (or 'Copay'): The fixed amount you pay every time you receive a benefit provided that care subject to a copay. For instance, a copay of $50 is applicable at a diagnostic center, and after that insurance company takes care of the remaining bill. § Coinsurance: It is the cost of your medicare percentage you bear. For instance, the cost of an ultrasound is $500 and you have to pay 20 percent ($80) on your own, and the rest of the bill is paid by the insurance company i.e. $420 so here the coinsurance is $80. § Annual out-of-pocket maximum: It is the maximum amount you pay out of your pocket in a year except the premium. It is the sum total of deductible, copays, and coinsurance) Your company would take over 100 percent of your covered costs once you reach this limit. It doesn't happen in most cases unless you are met with a really serious crisis and require to undergo serious treatment. What does it mean by covered benefit as the term is quite often used in insurance frequently? It is the health service that is promised after the payment of a certain premium for the concerning health policy. Covered implies some portion of the allowable cost of health service would be considered for payment by the insurance company but does not mean that it would be 100%. For instance, in a health plan that covers ‘urgent care,’ a copay might apply. Copay is an out-of-pocket expense for the patient. If the copay is $100 the patient has to pay this amount (usually at the time of service) and then the insurance plan 'covers' the rest of the allowed cost for the urgent care service. . Sometimes the insurance company does not pay for the covered benefit for example in case a patient has not yet fulfill the condition of an annual deductible of $1000 and the cost of the covered health service provided is $400, the patient will need to pay the $400 (often at the time of service). What makes this service 'covered' is that the cost counts toward the annual deductible, so only $600 would remain to be paid by the patient for future services before the insurance company starts to pay its share. It is worthwhile to mention here that MHN will not cover the copay for telehealth services now as they have been doing since the outbreak of the covid pandemic. The mental (tele) helth copay is going to be $25 from June 1st 2021 for each appointment with an MHN provider.