Health Insurance FAQ
Health insurance can seem confusing. Find out what it is, how it works, why you need it, how to find a plan, and much more.
- Medicare & Medicaid
What is health insurance, and why do I need it?
Going to the doctor or hospital can be very expensive. Health insurance helps you pay your medical bills. Just like car or home insurance, you pick a policy and pay a premium every month. As of 2014, we’re all required by law to have health insurance, and there’s a penalty if you don’t. Previously, it was tough to get health insurance if your employer didn’t offer it, but not anymore. With the Insurance Marketplace, the government is making it easy for you to find and afford the right option.
How does health insurance work?
Each health insurance plan is different and what works for your neighbor might not be a match for you and your family. But no worries—we’ll guide you through the important things to consider before you choose a plan.
Are all the things a plan covers.
Are what you pay for, like premiums, deductibles, and co-pays.
Refer to which doctors, facilities, and healthcare services a plan will and won’t cover.
How do I shop for health insurance?
There are lots of ways to get health insurance, so you can choose the one you’re most comfortable with. You can work with an insurance agent who can help you understand your options, or you can shop online yourself. Try to keep in mind which benefits are most important and why—this will help you focus and find a healthcare option for you.
What are health insurance benefits?
Benefits are services or products your health insurance covers. There are many different combinations of benefits you may get as part of your health insurance plan. The following are a few examples of benefits a plan might cover:
- Outpatient care (any medical treatment that doesn’t require an overnight stay at a hospital or medical facility)
- Trips to the emergency room
- Inpatient care (any medical treatment that requires admission to a hospital)
- Care before and after having a baby
- Mental health and substance use disorder services (includes behavioral health treatment, counseling, and psychotherapy)
- Prescription services
- Services and devices to aid recovery after an injury, or to help manage a disability or a chronic condition (includes physical and occupational therapy, speech language pathology, psychiatric rehabilitation, and more)
- Lab tests
- Preventative services (includes counseling, screenings, and vaccines to keep you healthy, and help manage chronic diseases)
- Pediatric services (includes dental and vision care for kids)
What are the other costs within health insurance?
Costs include a monthly fee called a premium for health insurance. You’ll also pay a fixed amount each time you use a specific service, like visiting the doctor. That’s called a co-pay. For example, if the plan has a $10 co-pay for doctor visits, you’ll pay $10 every time you visit the doctor. Depending on the plan and the service, some services are included/free and others have co-pays.
Important Cost Terms Explained
- A deductible is the amount you pay before your health insurance starts paying. It’s separate from the monthly premium you pay to have health insurance. After you have paid the full deductible amount, your insurance splits the bill with you. Many times, plans with high deductibles have low premiums, and plans with high premiums have low deductibles. NOTE: some plans count the co-pay toward your deductible, and others don’t, so read the fine print.
- Co-insurance is a percent of the total bill you are responsible for paying after you have reached your deductible. The remainder of your total bill will be covered by your health insurance. For example, if your co-insurance is 20%, for every dollar you spend on healthcare, you’ll pay 20 cents and your insurance will pay the other 80.
- Out-of-pocket maximums refer to the highest amount you’d pay for healthcare services in a year. If you reach that amount, your insurance pays 100% of your healthcare bills. NOTE: this excludes premiums.
What are networks?
A group of doctors and healthcare providers who have contracted with a health insurance company to offer their products and services at a pre-determined rate. You can use providers and pharmacies outside the network, but this will require you to pay more out of your pocket. If you have a specific doctor you want to see, you should make sure they’re in-network for the plan you choose.
There are two main types of plans to get to know before you buy. Also, if you have a specific doctor you’d like, that’s key.
If you choose a HMO (Health Maintenance Organization), you’ll have to see a doctor within your insurance network. You’re also required to have a Primary Care Physician (aka, a personal doctor), and if you need to see a specialist, or get X-rays or labs, you’ll need to first go to your personal doctor and then get a referral from him or her
If you sign with a PPO (Preferred Provider Organization), you’re not required to have a Primary Care Physician, and you don’t need a referral to see specialists, get labs, or X-rays. You can choose to see any doctor- in or out of the network. However, choosing someone outside will require you to pay the doctor more, and you’ll have to file an insurance claim to get reimbursed.
What should I consider before buying health insurance?
To find out what you and/or your family’s healthcare needs might be it’s helpful to look at your healthcare spending from last year (unless you’re expecting major changes). To get a better idea, try the tool below—estimates are just fine. Just remember that unplanned healthcare costs can pop up anytime, but having health insurance can offer some protection in those instances.
Healthcare Cost EstimatorAdd up you and your family's previous year's healthcare costs
Healthcare Costs Yearly Total Spent 1. Hospital Visit (e.g., emergency room visit) 2. Doctor Office Visits (e.g., Primary Care Visit) 3. Prescription Drugs (e.g., blood pressure medication) 4. Home healthcare (e.g., home nursing aide services) 5. Medical equipment and products (e.g., wheelchair) 6. Other Total previous year's healthcare cost $0000
To help you determine what’s important to you, rate the following on a scale from 1 to 3 based on importance (1 is mandatory, 3 not so much).
- Premiums vs. Deductibles: would you rather have lower premiums and higher deductibles (pay less in premiums per month, but more out-of-pocket when you need medical care)…OR, have higher premiums and lower deductibles (pay more/month, but less when you need to see the doctor)?
- Prescriptions: take a lot of these? Make sure they’re covered by your plan.
- Vision & Dental: do you need vision care? Would you like to have regular dental exams?
- Access to Personal/Wellness Tools & Coaching: are you managing a chronic disease? Do you want tips on maintaining a healthy lifestyle?
When shopping for plans, knowing the plan types below might be helpful.
Healthcare Plan Levels Price (Monthly Cost) Out of Pocket Costs Bronze Lowest Highest Silver Lower Higher Gold Higher Lower Platinum Highest Lowest
Can I afford health insurance?
Here’s how: the government is helping some people pay via subsidies and tax credits. Based on your family size, income, etc., you might be eligible for a subsidy that could decrease the cost of your premium. Try the below tool to see if you might qualify for a subsidy or tax credit.
NOTE: Quitting smoking may help decrease your premium too. Find out more about how to quit smoking by talking to a Walmart pharmacist.
When and where can I buy health insurance?
Individuals and families can go through the Health Insurance Marketplace or private insurance companies. Those who qualify for Medicaid or the Children’s Health Insurance Program (CHIP) can get insurance through them.
Health Insurance Marketplace
You can compare plans based on price, benefits, quality, and other important factors before you choose. The four categories of plans are: Bronze, Silver, Gold, and Platinum. You’ll also find “catastrophic” plans for those under 30 or with very low incomes.
Enrollment Period: November 1, 2017 - December 15, 2017
Coverage Begins: as soon as January 1st, 2017
Documents You Need to Enroll:
- Social Security Number (or document numbers for legal immigrants)
- Employer and income information for every member of your household who needs coverage (for example, pay stubs, W2 forms, or wage and tax statements)
- Policy numbers for any current health insurance plans covering household members
Provided through an employer or purchased individually through an agent.
Enrollment Period: varies depending on employer (always open if purchasing individually)
Coverage Begins: effective date determined at enrollment
Provides free or low-cost health insurance to lower-income individuals, families, pregnant women, and those with disabilities. Eligibility requirements are determined by state, so check with your local Medicaid office for more information. If you didn’t qualify before you might want to try again, as Medicaid eligibility may change every year.
Enrollment Period: open year-round
Coverage Begins: effective date determined at enrollment
Documents You Need to Enroll:
- If you’re a citizen: proof of identity, U.S. citizenship, or date of birth (e.g., a U.S. passport or driver’s license)
- If you’re not a citizen: proof of identity, immigration status, or date of birth (e.g., a green card)
- Proof of current income (e.g., pay stubs, a signed income tax return, etc.)
Children’s Health Insurance Program (CHIP)
Covers children of families who don’t qualify for Medicaid, but can’t afford to buy health insurance. Every state operates its own CHIP, often with a unique name—some states combine Medicaid and CHIP.
Enrollment Period: open year-round
Coverage Begins: at enrollment
What are the components of Medicare?
Refers to Parts A and B, which are run by the federal government. Part A covers hospital-related services and emergency care. Part B covers services like doctor visits, lab tests, immunizations, and necessary equipment like wheelchairs.
NOTE: if you don’t enroll in Part B when you’re first eligible, or if you drop it and get it later, you may have to pay a late-enrollment penalty for as long as you have Medicare (your monthly premium for Part B could go up 10% for each full 12-month period you could have had Part B)
Medicare Advantage (Part C)
Offered by private insurance companies, these plans replace Original Medicare. They cover benefits that Parts A and B cover and can offer additional benefits, like vision, hearing, and dental. Most plans also include prescription drug coverage.
Prescription Drug plan
Plans that help pay for prescription medications—they’re only available from private insurance companies
NOTE: you might not need this if you buy a Medicare Advantage plan that includes prescription drug coverage.)
It’s available from private insurance companies and helps pay out-of-pocket costs not covered by Medicare Parts A and B (Medigap isn’t available to Medicare Advantage members)
Original MedicarePart APart B
Medical Insurance+Part D
Prescription Drug Plan+Medigap
Medicare AdvantagePart C*
Replaces Parts A and B, available with
or without prescription drug coverage+Part D
Prescription Drug Plan
(If not included in primary plan)
* You must be eligible and enrolled in parts A & B to enroll in a Medicare Advantage Plan
How do I choose a Medicare plan?
Some Reasons to Consider:Original Medicare1. You want to be able to choose among doctors and medical providers (Medicare Advantage plans may have more limited networks)2. You’re not a fan of additional premiums (Medicare Advantage plans may charge an additional monthly premium)3. If you want to see a specialist without a recommendation (some Medicare Advantage plans may require you to get a referral from your primary care physician)4. You qualify for Medicaid (you might have different options)5. You have partial or full employee coverage (Medicare Advantage benefits might already be included in your existing coverage)Medicare Advantage1. You take prescription drugs (you’d have to pay extra for Part D under Original Medicare, but most Medicare Advantage plans include prescription drug coverage)2. You expect your out-of-pocket spending to be high (Medicare Advantage plans have an out-of-pocket maximum, so once you spend a certain amount you don’t have to pay for anymore covered costs—this doesn’t exist for Original Medicare)
Learn more about Medicare Part D plans at Walmart: www.walmart.com/rxplans
What’s the Medicare Coverage Gap?
An important point to understand is that there’s a gap in coverage for many Medicare Prescription Drug plans—it’s also called the Medicare Donut Hole. You and your plan pay up to $2,960 for covered drugs. After you reach that amount, you’re responsible for 45% of the cost for brand-name drugs and 72% for generic. That holds until you’ve spent $4,700. Once you reach this amount, you only pay a small coinsurance, or copayment, for covered drugs. People who get extra help for prescription drug costs won’t enter the coverage gap. Want to know whether you’d qualify for Extra Help? Check out https://www.medicare.gov/your-medicare-costs/help-paying-costs/save-on-drug-costs/save-on-drug-costs.html.
$0 - $2900
$2900 - $4700
How to stretch your Medicare dollar
Take Generic Drugs
Chat with a pharmacist about whether you can switch to a generic prescription that might cost less.
Price Shop for Durable Medical Equipment
Find the best deal on a blood sugar monitor, cane, walker, wheelchair, etc. through a government-approved supplier.
Use Your Yearly Medicare "Wellness Visits"
You and your doctor can use these appointments to create plans to help manage your health.
Manage Everyday Health Costs
Speak to your doctor about switching to lower-cost, over-the-counter products.
When do I enroll in Medicare?
Are You Newly Eligible for Medicare?
You can sign up for it three months before your 65th birthday, and three months after you turn 65. If you enroll before your birthday, coverage usually begins the first day of your birth month. There is a penalty for enrolling late, so enroll in that seven-month period. Some people get enrolled automatically—those under 65 with a disability, who have ALS (or Lou Gehrig’s Disease), or are already receiving Social Security Benefits might be automatically enrolled in Parts A and B of Medicare. Check www.medicare.gov to see if you’ll be automatically enrolled.
Are You Already Enrolled in a Medicare plan?
Open enrollment is from October 15th through December 7th every year. During this time you can change, enroll in, or add additional Medicare coverage. Changes take place January 1st of the following year. You don’t have to re-enroll every year, you just have the chance to make changes during this time period. However, plans do change from year to year, so it’s important to read the info your plan sends you. Especially the “Evidence of Coverage” and the “Annual Notice of Change.” To make sure you’re getting coverage that is a good fit for you and is coverage that you can afford, review your monthly premiums and benefits.
I’m ready, how do I enroll in a Medicare plan?
For Medicare Parts A and B:
- Enrollment Period: three months before and after you turn 65
- 1-800-MEDICARE (1-800-633-4227)
For Medicare Advantage, Supplemental, and Part D Prescription Drug Coverage:
- Enrollment Period: October 15th – December 7th, 2017
- TTY users should call: 711
- 8:00AM – 8:00PM local time, 7 days a week
- Click here to begin shopping for the best plan for you and your family
The Health Insurance Marketplace doesn’t sell Medicare plans.
If you’ve experienced a life event that impacts your coverage, there’s a Special Enrollment Period so that you can make changes—like for instance, if you…
- …move to a new area with different plan options, you may be able to switch plans for two months after you notify your carrier.
- …if you’re no longer eligible for Medicaid, you may be eligible to make changes for two months after losing coverage.
- For more information on Special Enrollment Periods, visit: http://www.medicare.gov
What do you need to enroll?
- Original Birth Certificate
- W2/Tax Forms
- Proof of Citizenship (Passport, Social Security Card, etc.)
Where can I get more information?
Visit the Healthcare Begins Here kiosk at your local Walmart. Market Point licensed representatives can also help you evaluate which private insurance plans might be a good fit. To find out when Market Point agents will be at your local Walmart store, use the tool below. https://www.directhealth.com/Schedule/Search
Services provided by a hospital, or another inpatient program, which could include X-rays, immunizations, lab work, and more.
Annual Election Period:
Also known as "open enrollment", this is the time when you can make changes to your Medicare coverage—it runs from October 15th to December 7th each year.
The services or products your health insurance covers. There are many different combinations of benefits you can get as part of your health insurance plan.
A fixed percent of the total bill you are responsible for paying after you have reached your deductible. The remainder of your total bill will be covered by your health insurance. For example, if your co-insurance is 20%, for every dollar you spend on healthcare, you’ll pay 20 cents and your insurance will pay the other 80.
The fixed amount you pay each time you use a specific service, like visiting the doctor. For example, if the plan has a $10 co-pay for doctor visits, you’ll pay $10 every time you visit the doctor. Depending on the plan and the service, some services are included/free and others have co-pays.
The amount you pay before your health insurance starts paying. It’s separate from the monthly premium you pay to have health insurance. After you reach your deductible, your insurance helps pay part of your bill, based on your co-insurance.
Medical Equipment (DME):
Doctor-recommended medical equipment that’s used in the home, like walkers, wheelchairs, or hospital beds.
Federal Poverty Level (FPL):
An income level that’s issued annually by the Department of Health and Human Services—the federal poverty level is used to determine eligibility for certain programs and benefits and differs by state.
Health Insurance Marketplace:
A new insurance marketplace that offers individuals and small businesses the ability to shop for qualified healthcare. It provides transparent and competitive information on health plans.
A group of doctors and healthcare providers who have contracted with a health insurance company to offer their products and services at a pre-determined rate. You can use providers and pharmacies outside the network, but it may require you to pay more out of your pocket.
Open Enrollment Period:
A one-time, three-month period when you can buy any policy sold on the Marketplace in your state—during this time you won’t be denied coverage, or charged more for past or present health problems. For Medicare open enrollment, please see “Annual Election Period” above.
Healthcare costs you pay because they’re not covered by insurance.
An agreement that outlines what costs the health insurance provider and the individual are each responsible for, along with what health insurance costs are covered.
The amount you or your employer pays for health insurance—it can be paid monthly, quarterly, or yearly.
To help people purchase health insurance, the government pays a fixed amount of a healthcare premium—subsidies are based on individual or family income levels.
Drugs and medications that legally require a prescription.
Prescription Drug Coverage:
Health insurance that helps pay for prescription drugs and medications. Generic prescriptions are the FDA-approved equivalent of brand drugs, and typically cost the least. Brand Preferred prescriptions don’t have a generic equivalent—they cost more than generic, but less than Brand Non-preferred. Brand Non-preferred are higher-cost medications that have recently come on the market.
Healthcare services that are meant to prevent illnesses and help keep you healthy through regular checkups and screenings (for example: Pap tests, pelvic exams, flu shots, and screening mammograms).
Primary Care Doctor/Primary Physician:
Doctors trained to provide basic care—patients see them first for most health problems. They can also make referrals to other health providers.
Qualified Health Plan (QHP):
Under the Affordable Healthcare Act, this is an insurance plan that’s certified by an Exchange or a Marketplace, provides essential health benefits, has limits on cost-sharing (like deductibles, co-pays, and out-of-pocket maximums), and meets other requirements. Public Exchanges are facilitated by the government, and Private Exchanges are facilitated by insurance companies.
For some services, or to see a specific medical provider, patients sometimes need a referral from a plan-approved professional.
Doctors that treat specific parts of the body, health problems, or age groups. For example, some doctors only treat heart problems.
An amount of money you can use right away (in the form of advanced payments) to lower your health insurance premium