Frequently Asked Questions
What is a deductible?
Your deductible is your up front financial responsibility before the insurance starts paying. Some services are deductible waved, check your plan summary for details.
What is co-insurance?
Co-insurance is the percentage split between you and the insurance company, after you meet your deductible. You may be responsible for 10%, 20%, 30%, 40%, or even 50% of the bill, after meeting the deductible but only up to the maximum out of pocket.
What is a maximum out of pocket?
Your maximum out of pocket is the most you will pay for covered services in a calendar year.
What is a co-pay?
A co-pay is a set amount that you pay for service. Often insurance plans will have co-pay’s for a doctor’s office visit, out- patient mental health visit, etc.
What is the premium?
The premium is the amount you pay to the insurance carrier for your health insurance plan.
What is a PPO?
PPO stands for preferred provider organization. With a PPO you can see in network medical professionals, or out of network medical professionals. Your benefits are much richer when using in network medical professionals.
What is an HMO?
HMO stands for health maintenance organization. You must chose a primary care physician who manages your care and refers you to in network specialists if necessary.
What is an EPO?
EPO stands for Exclusive Provider Network. You may see any contracted physicians, but the plan does not cover non contracted medical professionals or facilities.
What is an EOB?
EOB – Explanation of benefits. Provided by the insurance company to show how services billed were covered by your insurance. How much the medical provider billed your insurance company, how much the negotiated rates lowered the bill, how much was applied to your deductible, and what your financial responsibility is.
What is an SBC?
SBC – Summary of Benefits and Coverage, outlines how your coverage works. A requirement since health care reform, designed to help understand and compare coverage options from each carrier in a standardized format.
What is a Formulary?
A formulary is a list of the medications that your insurance covers. It’s important to check the formulary prior to purchasing you plan to ensure you have coverage for your medications.
What is an HSA?
HSA stands for health savings account. You must have an HSA compatible health insurance plan in order to contribute funds to a health savings account. A health savings account allows you to use pre-tax dollars to help pay for qualified medical and dental expenses. Go to for complete rules and guidelines.
What is a Open enrollment?
Open enrollment is the period when you can make changes to your benefits, or chose a new plan. If on an employer health insurance plan you will have open enrollment once a year, ask your company human resources professional when yours is. If on an IFP (Individual / Family Plan) the open enrollment period for 2015 plans is November 15, 2014 through February 15, 2015. Your new effective date will be determined by when your application is submitted. For Medicare Advantage and Part D plans the Annual Election period is October 15 through December 7 for changes that will be effective the following January 1.
What is Covered California?
Covered California is the state exchange for California where you can purchase health insurance, receive tax credit and subsidy if eligible.
How do you get paid?
Insurance agents are paid by the carriers for policies that they sell. I quote the same pricing that you will get directly from the carriers.

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