Medical Insurance primarily consists of 5 components:
Premium: This is the monthly membership fee you pay to the insurance company to subscribe to their services
Co-pay: This is a fixed/ variable amount that you pay your Doctor (PCP/ Specialist) per visit
Deductible: If your doctor recommends any tests/ procedures which are not covered as a part of your regular visit OR you need to get any treatment done -this is the amount that you pay before insurance company starts paying anything. This is a fixed amount defined in your plan.
Co-Insurance: This is the stage after you meet your set deductible. In this stage you pay some portion and the insurance company pays some portion of the cost, for e.g. 20/80
Max-Out of Pocket (MOOP): It’s the total amount you pay for co-pays, deductibles and coinsurance charges in a given time before your insurance company starts covering any additional expenses.
As part of the ACA (Affordable Care Act) also known as Obamacare – you may qualify for help paying for premium and reduced Co-pay/ Deductible/ Co-Insurance/ MOOP, based on your household income and family size.
Here is a link to 10 essential services that are covered as a part of major medical coverage.
Major medical generally has an Open Enrollment period (OEP) – during which anyone who is a legal resident can apply for insurance. Outside Open Enrollment you may qualify for Special Enrollment Period (SEP), for e.g. if you recently lost your coverage, moved out of your existing coverage area, gained immigration or have changes in your household size (because of birth, death, marriage, divorce etc.).