Health Insurance: A Necessity for Individuals & Businesses

For Individual & Family Plan Quotes & Consultation

Health care related expenses are of the most concerning issues facing Americans today. Obtaining health insurance coverage is not only a wise step but a necessary one to take. At Capital Shield, we assist our clients to find medical coverage that addresses their needs and fit their budgets. We achieve this by listening to the client’s concerns and educating them about the available options that can fulfill their needs.

Metal Tiered Plans: With the inception of the Affordable Care Act of 2010, also known as Obamacare, medical plans in America, for both Individual & Business Group Plans, were grouped into 4 tiers: Bronze, Silver, Gold, and Platinum. The grouping took place based on the richness of the plans with Bronze plans having the highest deductibles, annual out of pocket maximums and co-pays in exchange for the lowest monthly premiums, and, the Platinum plans with the lowest deductibles, annual out of pocket maximums and co-pays that carry the highest monthly premiums.

The following are descriptions of important health insurance terms that relate to both Individual as well as Business Group Plans.

  • Annual out of Pocket Maximum: This is the maximum amount that the insured will be liable for, within a year, towards any & all medical related expenses (excluding plan monthly premiums). In other words, the insured’s annual out of pocket maximum is limited to a certain dollar amount, beyond which he/she will not be liable for any additional incurred expenses. So, it can be said that by purchasing health insurance coverage, you are essentially limiting your losses/liabilities to a certain dollar amount. As an example, if an annual out of pocket maximum is $7,500, it would mean that no matter what the incurred expenses, the maximum dollar amount that would have to be paid by the insured towards the incurred medical expenses would not exceed the $7500 in any given calendar year.
  • Annual Deductibles & Co-pay: Annual deductibles can be viewed as the step before reaching the annual out of pocket maximum amount. The deductible amount is typically what the insured has to pay upfront before the insurance company will start its contributions towards the incurred medical expenses. After the deductible is met, the insured goes on a “copay”, e.g. 20% or 30%, until the annual out of pocket is reached. The deductible is created to prevent the insured from facing a sudden large financial obligation. The following simplified formula is intended to illustrate the concept more clearly:
  • [Medical Expenses – Deductible = Remainder * Co-pay until the Annual Max is met]
  • Negotiated Rates: This refers to the lower prices for health services that Health insurance companies have been able to negotiate with the participating medical facilities. Negotiated prices are another advantage of having health insurance coverage. The participating physicians & facilities are known as the “In-Network”.
  • Annual Check-up & Preventive Care: Due to the recent changes in the health care industry, all preventive care & annual check-up procedures are now free of charge and therefore not subject to plan deductibles. An example of a preventive care procedure for women would be a mammogram exam.
  • Doctor Visits: To keep the medical insurance premiums low, insurance companies have limited their offerings of doctor visits to 2-3 times per year on some of their plans. The copay for a doctor visit can range anywhere from $25 to $50 per visit that is not subject to the deductible. Of course, there are still plans that offer unlimited Doctor visits per year, however, that would translate into higher premiums which may be unnecessary for a healthy individual.
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