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Health Care Reform:

Health Insurance & Affordable Care Act

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Summary of benefits, also called benefits package

This is a list of what a health insurance plan covers. You will pay some of the cost as a copayment or as co-insurance. Your health plan will cover some, or all, of the rest of the cost.

Look at the benefits summary for each health plan you are considering before you buy one.;

The summary includes:

Covered services: Any care and treatment a health plan pays for -- whether it pays for part or all of it -- is a covered benefit.

Deductible amounts: The deductible is how much you must spend before your insurance starts to pay its part.

Copay or coinsurance amounts: With some plans, after you've paid the full deductible, the part that you pay for care is called a copay. It’s a fixed amount you pay each time for a certain type of care. For instance, you might have a $20 copay for a doctor's appointment and a $30 copay to see a specialist.

With other plans, after you've paid the full deductible, the part you pay for care is called a coinsurance amount. Coinsurance is a percentage of the total cost that you must pay. For instance, if your co-insurance is 20%, you pay 20% of the charge for each type of care you get. So if the bill was $100, you would owe $20.

Cost for prescription medicines: In the summary of benefits, find the section about prescription medicines and look at what you pay for a generic medicine and for a brand name one.

Limits to coverage: A plan may have a limit to how much you have to pay for covered care each year and for your whole life. You may hear people call this an out-of-pocket limit. Once you reach that limit, the plan pays 100% for your care.

The plan can also have limits for how much it will pay. An annual limit, for instance, is the most a plan will pay for certain services, like prescriptions or hospitalizations. Health plans sold in a Marketplace or ones from your employer cannot have an annual limit.

A lifetime limit is how much a plan will pay for services throughout your life. Health plans sold in a Marketplace cannot have a lifetime limit. A health plan you get through your employer can’t have one either.

There may also be an annual limit on how many times you can have a service. For instance, you may be covered for only one eye exam a year and for up to 10 visits to a mental health counselor.

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