You know you need health insurance. Then you start looking at plans and see words like premium, deductible, coinsurance, and provider network.
It can be hard to know where to start or to be confident that you’re choosing the best plan.
The good news is you do not need to memorize every insurance term before Open Enrollment. But you do need to understand the costs that affect your budget, the doctors and prescriptions that are covered in a plan and the steps to enroll.
This guide explains the basics. You can also use BeWell’s step-by-step “How To” resources when you are ready to browse plans or apply for coverage. And you’re never alone—our Certified Assisters are here to help, at no cost to you!
What Is Health Insurance?
Health insurance helps pay for covered medical care. You pay an insurance company a regular amount called a premium to keep your plan active. Depending on what is covered under your health insurance plan, you and the insurance company may share the cost of care.
Every health plan offered through BeWell covers 10 essential health benefits:
- Doctor and outpatient care
- Emergency services
- Hospital care
- Pregnancy, maternity, and newborn care
- Mental health and substance use disorder services
- Prescription drugs
- Laboratory services
- Preventive care
- Rehabilitation services
- Children’s health services
Plans available through BeWell must also cover treatment for pre-existing conditions. This means a plan cannot reject you or charge you more because of a health condition you had before your health insurance coverage started.
Key Health Insurance Terms to Know
Here are a few of the common health insurance terms you will see while shopping for a plan. Knowing these definitions will help you better understand what you may need to pay when you visit a doctor, fill a prescription or get care at the hospital:
- Premium: Your premium is the amount you pay each month to keep your health insurance active. You pay the premium even during months when you do not use your health insurance benefits.
- Deductible: Your deductible is the amount you may need to pay out-of-pocket for covered care before your health insurance plan starts to cover the cost. Some services may be covered before you meet the deductible. Check your health insurance plan documents to understand what your specific plan covers.
- Coinsurance: Coinsurance is a percentage of the cost of covered care after meeting your deductible. For example, if your coinsurance is 20%, you pay 20% of the plan’s allowed cost and the insurance company pays the rest.
- Copay: A copay is a fixed amount you pay for a covered service. For example, a plan may charge a copay when you go to a primary care visit or a specialist appointment.
- Out-of-Pocket Maximum: The most you will have to pay during a plan year for covered, in-network services. After you reach the maximum, the health insurance plan pays the full cost for covered, in-network services for the rest of the plan year. Premiums, non-covered services and some out-of-network costs do not count toward the out-of-pocket maximum.
- Prescription formulary: This is the list of prescription medications covered by a health plan. Plans may cover medications at different cost levels, have rules about which pharmacies you can use, how much you can get at one time or whether approval is needed to cover a drug.
Looking for another definition? Visit the BeWell health insurance terms glossary.
What Is a Provider Network?
A provider network is a group of doctors, clinics and hospitals that accept a health insurance plan. You will usually pay less when you get care or services from an in-network healthcare provider. Depending on the plan, non-emergency care outside the network may cost more or may not be covered.
Before choosing a plan, check whether it includes:
- Your primary care provider
- Specialists you see
- The closest hospital or urgent care center to you
- Clinics that are practical for you to reach
- Your preferred pharmacy
Check whether the plan you want is a Health Maintenance Organization (HMO) plan or a Preferred Provider Organization (PPO) plan. These types of plans have different rules for what is covered in-network and out-of-network. Get more information about HMOs and PPOs.
One thing to remember: Provider networks can differ between plans offered by the same insurance company. Look at the details for your specific plan, not just the insurance carrier’s name.
What Do Bronze, Silver, Gold and Turquoise Mean?
BeWell groups available health plans into Bronze, Silver and Gold levels, as well as Turquoise plans. These levels describe how much you may pay for plan benefits. They do not rank the quality of doctors or medical care:
- Bronze plans tend to have lower monthly premiums and higher costs when you receive care.
- Silver plans tend to fall between Bronze and Gold for monthly and out-of-pocket costs.
- Gold plans tend to have higher monthly premiums and lower costs when you receive care.
- Turquoise plans may provide added out-of-pocket savings for eligible New Mexicans.
Curious about coverage? Compare Bronze, Silver, Gold and Turquoise plans.
When Can You Enroll in Health Insurance?
During Open Enrollment
Open Enrollment is the set period each year when eligible people can enroll in or change Marketplace health plans. The exact dates should be checked each year. Preparing early gives you time to compare plans, collect information and ask questions before the deadline. Read about Open Enrollment and Special Enrollment.
In a Special Enrollment Period
A Special Enrollment Period may let you enroll outside Open Enrollment after having certain life events, such as:
- Losing other health coverage
- Getting married
- Having or adopting a child
- Moving
- Turning 26 and losing coverage through a parent
Native Americans living in New Mexico can enroll through BeWell or make coverage changes year-round. See options for Native Americans.
Helpful Resources for Every Step!
BeWell’s Help library includes written instructions and videos for many enrollment and account tasks. Start with the resource that matches what you need to do:
- Browse and compare health insurance plans
- Create a BeWell account to apply for coverage
- Complete your application for coverage
- Enroll after a life change
- Ask for personal help
You don’t have to learn every insurance term before you shop for a plan. Start with the details that affect your household most, such as prescription coverage or out-of-pocket costs for coverage. Then compare the plan documents before making a choice.
If you have questions, BeWell’s Certified Assisters are standing by to help. Schedule a free appointment with a Certified Assister—we’re here to make finding and getting health insurance coverage easier for you.
