Since the passage of the Affordable Care Act (establishing what is generally known as Obamacare), most people’s access to affordable health insurance is greater than it has been. But navigating Healthcare.gov can be a complicated task with a myriad of confusing choices to make. Here are some touchpoints you can keep in mind as you move forward in choosing a health insurance plan, whether through the Marketplace or on your own. We recommend starting with the Marketplace as private health insurance is often significantly more expensive. If your employer offers insurance, this mostly won’t apply to you — but if you have a choice of plans through your employer, it’s still good to know the information below.
There are 5 categories of Marketplace insurance plans (in order from lowest to highest premiums): Catastrophic, Bronze, Silver, Gold, and Platinum. Plans in these categories differ based on how you and the plan share the costs of your care. Catastrophic plans offer the lowest premiums with the highest deductibles (i.e. what the insurance expects you to pay upfront before your coverage will kick in). Platinum plans have the highest premiums with the least out-of-pocket costs, and the others fall somewhere in the spectrum. How much you can comfortably afford to spend on health insurance each month should be your starting point for determining what health plan to pick.
Obviously not all medical costs can be predicted, but if you have a chronic condition of any kind you probably have a reasonable idea of your basic medical needs for the year — how many doctor/specialist visits, prescriptions needed, etc. You will save the most money by estimating this in advance and choosing your health plan accordingly. Weigh the amount you will spend each year on premiums with how often you go to the doctor. The more you go, the more you’ll need a plan with good coverage. The higher premium will still save you the most money in the long run if you have a great need for medical care; it may be worth the financial risk to go with a higher deductible, lower premium plan if you are in good health and relatively young.
Every plan has slightly different features — deductible amount, copayment amount for PCP (primary care physician) and specialist, network coverage, services covered, and the list goes on and on. You’ll want to go over each possible plan with a fine-tooth comb and an eagle eye to make sure that you are getting the best deal for your money and the best fit for your medical needs. Of primary importance, though, is the amount you’ll be required to pay out-of-pocket. The deductible, the copayment, and the coinsurance are the patient’s responsibility. Deductibles range from $0 to several thousand dollars depending on the plan. Copays are not included with all plans, but they generally start at $20 for a PCP visit and $40 for a specialist. Some plans also require coinsurance, meaning that the insurance will expect you cover a portion of the service yourself (often this is 20% but can be as high as 50%). Depending on the amount of medical care you need in a year, you will need to weigh the financial responsibility you’d be willing to assume.
If you go to a doctor you really like, you’ll need to consult with them to see which insurance plans they are in-network with before choosing your own. Going to a doctor/lab/specialist out-of-network can be significantly more expensive as most insurance plans pay less. The lower tier Marketplace plans often are much stricter about their networks and their out-of-network payments. If you’ve recently moved, you’ll still want a larger number of doctors to choose from; make sure you pay special attention to the network (or lack thereof) in the insurance plan you’re investigating.
Please note: enrollment is currently closed at Healthcare.gov but reopens again November 1st. If you have a special situation (such as losing a job or losing insurance through a life event), you might still qualify for 2015 insurance; click on the above link for more information and to apply.
The Alliance For Affordable Services has been committed to the idea of affordable healthcare for many years. Members have numerous health and wellness benefits; such as mail order pharmacy discounts, a 24/7 on-call doctor information hotline, financial assistance for maintenance medications, discounts on lab tests and diagnostics, and a plethora of emergency-related benefits and assistance. Should the Marketplace not cover your insurance needs or if you not qualify for a subsidy, the Alliance offers members access to the American Health Insurance eXchange where a licensed health care professional can help guide you through the process of selecting a health plan. For more information, and to become an Alliance member, visit the Alliance Direct Benefits website today or call us at 1-800-733-2242 (M-F, 7am-5:30pm Central Time).