All plans offered to people who purchase an Individual and Family plan must include the 10 Essential Health Benefits (EHBs) listed below:

1. Hospitalization
2. Prescription drugs
3. Laboratory services
4. Pregnancy, maternity and newborn care
5. Ambulatory outpatient services
6. Emergency services
7. Mental health and substance use disorders
8. Rehabilitative care
9. Preventive and wellness services
10. Chronic disease management

During Open Enrollment, which runs from November 1 to January 15 every year, you can buy a new plan, renew your plan, or switch plans.

During the Special Enrollment Period, from January 16 to October 31, you may be able to shop for or make changes to your plan within 60 days of having a qualifying life event, including the loss of health coverage, changes to your household, a change in residence, or another event like becoming a U.S. citizen or a change in your income that may affect the coverage you quality for. For more information on qualifying life events, visit healthcare.gov.

With the Affordable Care Act, the federal government created four metal levels, or categories of coverage, to help people more easily compare plans from different health insurance companies: Bronze, Silver, Gold and Platinum. Plans are assigned to one of these levels based on what percentage of the cost of health care services is covered by the health insurance company.

All products cover the Essential Health Benefits (EHBs) set forth by the ACA, such as doctor visits, prescription drugs, x-rays and hospital stays. The major differences are in what you pay when you receive these services and the monthly cost (the premium) of the health plan.

A primary care provider (PCP) is the health care provider you see for most of your health care needs. Health Maintenance Organization (HMO) plans typically require you to select a PCP to coordinate your care. To find a primary care provider, use our online directory.

Health Maintenance Organization (HMO) and Exclusive Provider Organization (EPO) plans from Jefferson Health Plans require you to choose doctors and hospitals within our network in order to get coverage for services. Preferred Provider Organization (PPO) plans provide coverage for providers in the network and outside of the network. You will save more when you choose an in-network provider, hospital, or facility. Use our online directory to find in-network providers covered under your plan.

Yes. Our plans include $0 virtual visits through JeffConnect, which provides you with 24/7 access to a Jefferson Health board-certified provider for medical concerns that are not an emergency.

HMO stands for Health Maintenance Organization. HMO health plans typically require you to select a primary care provider, or PCP, to coordinate your care and to refer you to other providers when needed for specialty care. With a Jefferson Health Plans HMO plan, referrals are not required. Services are covered when you seek care from providers within the HMO network. If you go outside of the network for care, typically only emergency services are covered.

Yes. All plans from Jefferson Health Plans cover mental health and substance abuse services.

Your health care coverage is considered in-network when you use a provider, hospital, or facility that participates in our network. To find out if a provider is in-network, use our online directory

Yes. With Jefferson Health Plans, you are covered for medically necessary services for unexpected illnesses or emergency care no matter where you seek care.

Yes. All Jefferson Health Plans provide prescription drug coverage for generic and brand name medications.

The drug formulary is a list of medications selected by Jefferson Health Plans for their medical effectiveness, positive results, and value. It includes all generic medications plus a defined list of brand-name medications. You can save money by utilizing medications that are included on the formulary.

To locate a participating pharmacy, use our convenient search tool.

Yes. Our health plans offer low-cost generic Tier 1 and Tier 2 drugs with no deductibles. Generic drugs are as safe and effective as brand-name drugs and could cost less.

A copayment, or copay, is the fixed amount you pay for doctor’s visits, prescriptions, or other services.

A deductible is the fixed amount you pay for covered medical services before your insurance kicks in. For example, if your plan has a $1,000 deductible, you will need to pay the first $1,000 of the costs for health care services. Once you have paid this amount, your insurance will begin to pay a portion, or all, of your health care costs, depending on the health plan.

If you choose a health plan with a high deductible, you will have a lower monthly premium. If you choose a health plan with a low deductible, you will have a higher monthly premium.

This is the maximum amount you’ll pay for health care services in a plan year. Care for covered services you receive after you reach the out-of-pocket maximum will be fully covered by the health plan. Out-of-pocket maximums vary by plan and can be found in your plan brochure or summary of benefits & coverage document. The out-of-pocket maximum does not include premiums or charges for covered services that are not Essential Health Benefits (EHBs).

This is a tax credit you can take in advance of your monthly health insurance payment (or “premium”) based on your expected income. If you qualify for a premium tax credit based on your income, you can use some or all of this tax credit to lower your premium payment. Keep in mind that premium tax credit is available only available on plans purchased on the marketplace.

This is a discount that lowers the amount that you pay out-of-pocket for healthcare expenses, including your deductibles, copayments, and coinsurance. After you reach the out-of-pocket maximum, your health plan covers 100% of all covered services. If you qualify for cost-sharing reductions, you must enroll in a plan in the Silver category to get the extra savings. Keep in mind that, like the Premium Tax Credit, Cost-Sharing Reductions are available only on plans purchased on the marketplace.

Jefferson Health Plans Health Maintenance Organization (HMO) plans include providers in the network that are grouped into Tiers, Tier 1 and Tier 2. Your cost will vary depending on which Tier your provider is in, with Tier 1 providers costing less and Tier 2 providers costing more. Both Tiers provide you with access to high quality, affordable providers.