Health Insurance Basics

Why Health Insurance Matters

Health insurance is for medical assistance that may cost too much to pay for all at once by yourself, such as a broken leg or a hospital stay. Health Insurance Pays - Nobody plans to get sick or hurt, but most people need medical care at some point. Health insurance coverage helps pay for these costs and protect you from very high expenses. Did you know that the average cost for a 3-day hospital stay is $30,000? Health insurance may also help pay for any number of smaller medical costs, including everything from doctors’ appointments to prescriptions. Most Montanans are used to paying for certain kinds of insurance, like car insurance or home owner’s insurance, which protect us when we are involved in a traffic accident or when we suffer a house fire. Generally, insurance helps us manage risk.

Health insurance also matters because it is now required in the United States and there are potential tax penalties if you or your kids aren’t covered. If you don’t have coverage in 2017 and you don’t qualify for an exemption, you’ll either pay 2.5% of your annually household income or $695 per adult and $347.50 per child, whichever is higher. Find out more about health insurance tax penalties here.

Types of Health Insurance Plans

Where you get health insurance coverage depends on your job, family, and income. Many Montanans get their health insurance through their employer or their spouse’s employer. Those who are not offered employer coverage (or those who face unaffordable employer coverage) can access health insurance through the new Health Insurance Marketplace.

The Health Insurance Marketplace (accessed through connects individuals and families to both private health insurance plans and public health insurance plans, including Montana Medicaid and Healthy Montana Kids. This is done through a single, streamlined application in which you will instantly receive your eligibility results.

The Health Insurance Marketplace is also the only place where you can take advantage of the new Advanced Premium Tax Credit (APTC). This new tax credit helps make insurance more affordable – and more than 80% of Montanans qualify. Check out our calculator to see if you and your family are part of that 80%.

What Does a Health Insurance Plan Cover?

While health care reform has made health insurance a requirement, it has also improved and streamlined what all health insurance plans must cover. Most health insurance plans cover ten essential health benefits:

  • Outpatient care (medical are received without being admitted to a hospital).
  • Emergency services.
  • Hospitalization (including surgery and overnight stays).
  • Maternity, pregnancy, and newborn care.
  • Mental and behavioral health care, including substance use treatment.
  • Prescription drugs.
  • Rehabilitative and habilitative services and devices (services and devices that help patients with injuries, disabilities, or chronic conditions gain or recover mental and physical skills).
  • Lab services.
  • Preventive care, wellness services, and chronic disease management.

For children, dental coverage is also included in coverage. On the Health Insurance Marketplace, adults have the option to purchase a dental plan in addition to their health plan.

While most health insurance plans cover these essential health benefits, each plan will have different amount of cost-sharing and out-of-pocket costs associated with accessing these health services. 

Understanding and Using Your Health Insurance

Especially if you are new to health insurance, learning about coverage can involve a lot of new information and unfamiliar terms. Fully understanding your health insurance is key to getting the most out of your coverage.

Here are few tips that will help:

Understand your monthly premiums and out of pocket costs. Each month, you are required to pay your monthly insurance premium to stay enrolled in your health insurance plan. This is similar to how you pay for your your car insurance or home insurance. When you need to see a doctor, there will usually be an out-of-pocket cost that you must pay at your appointment, sometimes called a co-pay or co-insurance. Co-pays are in addition to the monthly premium you pay. Some insurance plans will require that you meet a deductible before they pay any amount toward your care.

Know your health insurance network. Your provider network is a list of health care providers and hospitals that your health plan has contracted to provide medical care. A doctor or hospital who is included in your networks is considered “in network” or a “network provider,” while those outside your network are “out of network.” Find out more provider networks here.

These are just some of the basics. Another great resource for learning about using your coverage and improving you health is the Coverage to Care: Roadmap to Better Care and a Healthier You document. We also have an online glossary of health insurance terms and a Frequently Asked Questions page about the Health Insurance Marketplace that may help you find the information you need.

Montana Health Coverage

Still have questions? Remember, that you are not alone! If you have questions about insurance basics or how to pick a plan that is right for you, find a local enrollment assister who can help.

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