FAQs

How do deductibles work? 
Deductibles are the first portion of a medical bill for which the insured is responsible. If you have a plan with doctor office copays, the copay “waives” the deductible, meaning that 100% of the doctor visit expenses are covered after the copay is paid. Expenses that are not covered with a copay, such as MRIs or surgery are subject to the annual deductible. This means that once the service is rendered the insured receives a bill from the provider and an explanation of benefits (EOB) from the insurer. The EOB will show the billed charges from the provider, less any applicable discounts the insurer is entitled to, less any charges the insurer paid, leaving the deductible and any applicable coinsurance. Remaining charges will show up on the bill from the provider, and it is the insured’s responsibility to make payment.

Is everything covered after my deductible is met?
Not always. Most of the time there is cost sharing between the policy holder and the insurer, called coinsurance. Usually this amount is 80/20 or 70/30, meaning that the carrier pays 70% or 80% of expenses after the deductible, leaving the policy holder to pay the remaining 30% or 20%. Coinsurance has a cap that varies by insurer and plan, after which 100% of expenses are paid. For example, an insurer offers a plan with a $2,500 deductible and 80/20 coinsurance with a maximum out of pocket of $4,500. This means that the insured is responsible for the first $2,500 (the deductible) and then 20% of the next $10,000 of expenses ($2,000). $2,500 plus the coinsurance maximum of $2,000 equals the total risk exposure for covered expenses ($4,500).                                                                                                       
Do you have dental and vision plans?
PFI Benefits offers dental plans as separate plans or as part of a number of health insurance plans.

PFI Benefits offers vision plans as part of our small group plans or in combination with some dental plans. We do not carry vision plans as separate plans or as part of our individual health insurance plans.

When can I expect a rate increase on my insurance plan?
With almost all insurance policies, you’ll receive a 12 month guarantee on your monthly premium rate. This means that if your insurer raises their rates, your premium will not be affected until your annual renewal. There are just a few insurance companies that do not offer this guarantee.

Are pre-existing conditions covered by individual health insurance?
It depends on the carrier. Some carriers need a certain time clearance before they’ll consider covering a particular condition or illness. For example, a gastric bypass typically requires 3 years before most carriers will cover medical treatment for this condition. Some cancers require 5 years and others 10 years before treatment is covered for the same condition. In the case of strokes and heart attacks, unfortunately, no carrier will offer coverage for these conditions. However, PFI Benefits does offer individuals guaranteed issue insurance that covers any condition.

How do health insurance carriers determine monthly premium for insurance?
Insurers will offer their preferred or best rates to any applicant who is in good health. Insurers may determine different rates for those with certain medical conditions or a medical history. This means that an insurer may increase your premium up to 25% if you’ve had a history or had treatment for a variety of problems including breast implants, bronchitis, asthma or kidney stones. These same insurers may increase your premium up to 50% if you’ve had the same history or treatment recently (within 3-6 months) or more than one medical condition.

In other instances insurers will exclude coverage (add a rider) of a particular condition, disease or illness. This means that you won’t be covered for medical assistance, attention or prescriptions for that condition. Or, an insurer may add a condition-specific deductible to your policy. This means that a higher deductible will apply for any medical attention required for your specific condition.

How soon am I billed on my monthly premium?
Some insurers will automatically deduct your first month’s premium at the time you submit your application. Other insurers won’t charge you a monthly premium until your policy is issued. All insurers will accept credit, debit or electronic transfer payment for the first month’s premium. No insurer will accept ongoing premium payments from a credit card. You can request a paper bill pay from your insurer but some will require that you make quarterly rather than monthly payments if this is how you want to pay.