If you are not offered health insurance by your employer, if you’re unemployed or self-employed, your best option for securing health insurance is through an Affordable Care Act (ACA) marketplace.
There’s a federal marketplace called healthcare.gov, but a number of states operate their own marketplaces. The marketplace is just what it means, a place where you can shop around for an insurance policy from different insurers and with different levels of premium and coverage.
The key when choosing a plan on the marketplace is getting the coverage and premium levels right. It’s a delicate balance that requires that you assess your life, health and financial circumstances.
The least expansive plans on the marketplace will typically have higher out-of-pocket costs, while the higher the premium, the more generous the coverage. That said, all plans are required to cover (with no cost-sharing on behalf of the enrollees) 10 essential benefits, which we’ll outline below.
Here’s what you need to know if you’re in the market for health insurance.
Precious metals
Health plans on the marketplace cover the same things as employer-sponsored plans: doctor visits, outpatient and inpatient care, specialists, prescription drugs, emergency care and mental health services. They are also either preferred provider organizations (PPOs) or health maintenance organizations (HMOs).
For simplicity’s sake, marketplace plans indicate coverage levels by metal tiers, from low premium and higher out of pocket costs, like copays, coinsurance and deductibles to high premium and lower out-of-pocket expenses. On average plans pay the following percentages of your medical expenses, with the rest covered by the enrollee:
- Bronze: 60%
- Silver: 70%.
- Gold: 80%
- Platinum: 90%
The above are averages and out-pocket-costs are capped at the deductible for any plan. So if someone has a serious health issue they may pay no more than the deductible.
What plans cover
The ACA requires health plans in the marketplace to cover at a minimum the 10 essential health benefits:
- Ambulatory/outpatient care
- Emergency care
- Hospitalizations
- Laboratory services
- Mental health and substance use services
- Pediatric services
- Pregnancy, maternity and newborn care
- Prescription drugs
- Prevention and wellness services
- Rehab and habilitative services
The choices
Marketplaces offer a number of insurance arrangements:
- HMO: HMOs require enrollees to get their health care services delivered its network of doctors only. If you go out of network for anything but emergency services the plan won’t cover it. If you need to see a specialist, your doctor must refer you. These plans are typically priced lower than other plans.
- PPO: These plans are less restrictive than HMOs. It will offer more generous coverage if you go to a network physician, but these plans may also partly cover out-of-network care. You also don’t need referrals if you want to see a specialist. These plans cost more than HMOs.
- Exclusive provider organization: These plans require you to stay in network if you want care to be covered, but they don’t require that you get a referral before seeing a specialist.
- Point of service: These plans are rare. These plans will cover out-of-network care, but they require you to name a primary care physician who must refer you if you want to see a specialist. These plans are the most expensive.
When you can sign up
You can purchase a plan anytime on a marketplace after a qualifying life event, like:
- Losing your health insurance coverage.
- Having a baby or adopting a child.
- Getting married.
- Getting divorced or separated.
- Death of a spouse or dependent.
- Moving to a new ZIP code.
- Income changes that make you eligible for ACA marketplace premium tax credits.
- Losing Medicaid eligibility.
- Aging out of your parent’s health insurance when you turn 26.
Signing up
Marketplaces also have annual open enrollment periods that last from Nov. 1 through Jan. 15 in most states. States with their own marketplaces may have slightly different dates for open enrollment.
This is your chance to change plans if you are already in one. The marketplace can be confusing and there is a lot of information to sift through.
To reduce the stress, let us help you sign up or enroll again for next year. We’ll gather your information and help you find a plan that is best for your health, life and financial circumstances.
