General Health Insurance Questions🩺

Q: Why is health insurance considered a key part of a financial protection plan rather than just medical coverage?
A: Because health insurance does more than pay medical bills — it protects your long-term financial stability. A single hospital stay can cost tens of thousands of dollars, and without coverage, those costs could derail savings or retirement plans. Health insurance shifts much of that financial risk to the insurer, allowing you to budget predictably and preserve assets.

Q: How does health insurance encourage preventive and early-stage care instead of only covering major illnesses?
A: Modern health plans are designed to promote proactive wellness by fully covering annual exams, screenings, and vaccinations. This preventive approach helps detect health issues early — when they’re easier and less expensive to treat — improving both outcomes and cost efficiency over time.

Q: What’s the long-term advantage of maintaining continuous health insurance coverage, even when you’re healthy?
A: Staying insured continuously ensures uninterrupted access to care and protects against future restrictions or gaps in coverage. It also helps you establish a consistent healthcare record, which can improve treatment coordination between doctors and hospitals.

Q: What’s the difference between an HMO and a PPO?
A:

• • • HMO (Health Maintenance Organization): Requires you to use doctors within the plan’s network and get referrals to see specialists.

    • PPO (Preferred Provider Organization): Offers more flexibility—you can see any doctor, even out-of-network, often without a referral.
      
      

Q: What is a deductible?
A: A deductible is the amount you pay out-of-pocket for medical services before your insurance begins to share the costs.

Q: What is a premium?
A: A premium is the amount you pay each month to keep your health insurance active.

Costs and Coverage💱

Q: What is a copay?
A: A copay is a fixed amount (for example, $20) you pay for certain services like doctor visits or prescriptions.

Q: What is coinsurance?
A: Coinsurance is the percentage of costs you share with your insurer after meeting your deductible (e.g., you pay 20%, insurance pays 80%).

Q: What’s the difference between in-network and out-of-network care?
A: In-network providers have contracts with your insurance company, which means lower costs for you. Out-of-network care usually costs more.

Q: What does “out-of-pocket maximum” mean?
A: It’s the most you’ll pay during a plan year for covered services. Once you reach that amount, your plan pays 100% of covered costs.

Q: Do all plans cover prescriptions?
A: Most plans include prescription drug coverage, but the list of covered medications (called a formulary) can vary by plan.

Enrollment and Eligibility📝

Q: When can I enroll in health insurance?
A: You can enroll during the Open Enrollment Period or during a Special Enrollment Period if you experience a qualifying life event such as losing coverage, getting married, or having a baby.

Q: What is a qualifying life event (QLE)?
A: A QLE is a major change in your life—like marriage, divorce, job loss, birth of a child, or moving—that allows you to enroll or change your coverage outside of Open Enrollment.

Q: Can I get help paying for my insurance?
A: Yes. Depending on your income and household size, you may qualify for premium tax credits or cost-sharing reductions through the Health Insurance Marketplace.

Q: What’s the difference between Marketplace plans and employer insurance?
A: Marketplace plans are purchased individually through state or federal exchanges, while employer insurance is offered through your job and may be partially paid by your employer.

Using Your Insurance⚕️

Q: How do I find out if my doctor is covered?
A: You can check your insurer’s online provider directory or call your insurance company to confirm your doctor is in-network.

Q: Do I need a referral to see a specialist?
A: It depends on your plan. HMOs usually require referrals, while PPOs generally do not.

Q: What should I do in an emergency?
A: In a life-threatening emergency, go to the nearest hospital—your plan must cover emergency care even if the hospital is out-of-network.

Q: How do I file a claim?
A: If you visit an in-network provider, they typically file the claim for you. If you go out-of-network, you may need to submit a claim form with itemized bills.

Family and Preventive Care🏥

Q: Can I cover my children on my plan?
A: Yes, most plans allow you to cover dependents up to age 26, regardless of their student or marital status.

Q: Are preventive services free?
A: Yes. Most plans cover preventive services—like annual checkups, vaccinations, and screenings—at no cost when provided by in-network doctors.

Q: What is considered preventive care?
A: Preventive care includes routine health services designed to help you stay healthy and detect potential issues early. Examples include annual checkups, vaccines, cancer screenings, blood pressure checks, and wellness counseling.

Q: Do I have to meet my deductible before preventive care is covered?
A: No. Most preventive services are covered at no cost to you when you see an in-network provider, even if you haven’t met your deductible for the year.

Q: Why is preventive care important?
A: Preventive care helps identify health problems early—when they’re easier and less expensive to treat. It also helps you maintain better long-term health and can reduce your overall medical costs over time.

Marketplace / ACA Questions⚖️

Q: What is the Affordable Care Act (ACA)?
A: The ACA is a law that expanded access to health coverage, required essential benefits, and prevents insurance companies from denying coverage for pre-existing conditions.

Q: What are essential health benefits?
A: These are 10 categories of care all Marketplace plans must cover, including hospitalization, prescriptions, maternity care, and preventive services.

Q: What happens if I don’t have health insurance?
A: There’s no longer a federal penalty, but some states may charge a fee for being uninsured. Without insurance, you’ll also be responsible for the full cost of care.

Broker Assistance🆘

Q: Can a broker help me choose a plan?
A: Yes. Licensed brokers can help you compare plans, check eligibility for savings, and complete your application—usually at no extra cost to you.

Q: What does a health insurance broker do?
A: A broker is a licensed professional who helps you compare health plans, explain benefits, and find coverage that fits your needs and budget. Brokers act as your personal advisor—making sure you understand your options before you enroll.

Q: Is there a cost to work with a broker?
A: No. There is no additional cost to use a broker. Brokers are compensated by the insurance companies or exchanges, not by you.

Q: Why should I use a broker instead of enrolling on my own?
A: Brokers provide expert guidance to help you:

• • • Avoid common enrollment mistakes

    • Understand coverage differences between plans

    • Get personalized advice based on your doctors, prescriptions, and budget. In short, you get professional help without paying extra.

Q: Do brokers work with all insurance companies?
A: Many brokers are certified to work with multiple insurance carriers. This means they can show you a variety of plan options—not just one company’s products—so you can make an informed choice.

Q: Is my personal information safe when I work with a broker?
A: Yes. Licensed brokers must follow strict privacy and compliance rules to protect your personal data and ensure your enrollment information remains confidential.

Q: Can brokers help with both Marketplace and private health plans?
A: Yes. Brokers can help you compare Marketplace plans as well as off-exchange private plans for individuals and families who don’t qualify for subsidies.

Q: Can brokers help businesses with group health plans?
A: Definitely. Brokers can also help small businesses find group health insurance, assist with employee enrollments, and manage renewals and compliance.

Q: What’s the benefit of having a local broker?
A: Local brokers understand state-specific rules, local provider networks, and carrier options. They can explain coverage in plain language, and give you personalized, ongoing support.

💬 Need Assistance?

Our licensed brokers are here to help you understand your options, compare plans, and find coverage that fits your needs.

📞 Call us at: 410-855-5388
🌐 Visit: My Smart Health Plans
✉️ Email: CONTACT US

We’d be happy to help you review your options and get enrolled in the plan that’s right for you!

Disclaimer: Product features, and benefits described above may vary by insurance carrier, policy type, and state availability. Eligibility, coverage terms, and benefit amounts are determined by each insurance company’s official policy provisions. Please refer to your specific policy documents for complete details.