Your Health Insurance Marketplace 101 Guide To Open Enrollment

It’s that time of year again… Time for open enrollment. From November 1 through December 15 everyone will have the opportunity to sign up for a healthcare plan from the Health Insurance Marketplace (aka Obamacare). No need for a special enrollment period or qualifying event. So, if you’re self-employed and need a healthcare plan (which you do btw), now is the time to register and get yourself covered.

New to navigating the Marketplace? Here’s your 101 guide to healthcare vocabulary and a step-by-step breakdown to help you choose the best plan for you and your family in 2019.

I. Health Insurance Marketplace Vocabulary 101

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Before you can choose the right plan for you and your family, it’s important to understand the terms used throughout the Marketplace. Let’s start with basic healthcare vocabulary.

PPO vs. HMO vs. EPO - Major Differences

Depending on where you live, your area may have all of these options available or may only have one or two to choose from. In my professional opinion, PPO plans are preferable, followed by HMOs and EPOs.

PPO: Preferred Provider Organization

  • Less restrictive with the physicians that will take the coverage.

  • Do not have to see a primary care physician to get a referral to a specialist

  • Typically higher premium costs

HMO: Health Maintenance Organization

  • Gives you access to particular physicians within its network. The physicians you have access to are often assigned to you based off of your zip code.

  • You will need to see a primary care physician to get a referral to see a specialist.

  • Lower premiums in comparison to PPO plans.

  • NO out of network coverage.

EPO: Exclusive Provider Organization

  • Overall, EPOs are very similar to an HMOs with slightly lower premiums and are a bit more restrictive on the doctors that will take the coverage.

Premiums, Deductibles, copays… Oh, my!

Premium

  • Your monthly payment

Deductible

  • The amount of money you will have to pay out of pocket on top of the monthly premium before coverage will kick in and cover your costs.

Copays

  • Predetermined costs on certain things like doctor visits, specialist visits, prescription fills and ER visits. If the plan does not offer copays you will be required to pay for the total price of the visit every time you go to the doctor until you meet the deductible amount.

Typically if you opt for a lower premium payment, you will have a higher deductible and higher copay (if any). The lowest premium plans usually do not off any coverage until the entire deductible is met. On the other hand, if you can muster out a higher monthly premium payment, you will get a lower deductible and have preset copays that are lower in cost as well.

Medal levels: Bronze, Silver, Gold and Platinum

For the most part, the level you choose will determine the cost of the monthly premium in comparison to the size of the deductible and the cost of copays (if copays are offered).

Bronze level plans will have the lowest premiums and Platinum will have the highest.

Other words to know

Coinsurance

  • The percentage of service costs you will have to pay after you have met your deductible. Usually set up as 80/20 or 70/30 where you would pay the lesser percentage and the insurance would pay the higher.

Max Out of Pocket

  • It is the maximum amount you will have to pay for covered service in a year. All plans will have this number associated with them.

These two words work together. For instance: If your plan has a deductible of $100 and a coinsurance of 20% and you go to the hospital and rack up a bill for $2000, you would pay the $100 deductible and pay 20% ($380) of the remaining $1900 bill, until you reached your max out of pocket. So if your max out of pocket amount was $250, you would pay only an additional $250, even though the 20% was more than that. If your max out of pocket was $500, you would have to pay the $380, and you would still have a remaining $120 to pay if you went back to the hospital… but you wouldn’t have to meet your deductible again!

II. Step-by-Step

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Now that you’re a pro at Marketplace vocabulary, here is how to navigate healthcare.gov to find your ideal plan:

Go to healthcare.gov.

You’ll be prompted to enter your basic info like zip code, age, income, and the number of people to be insured. (You can either create a log-in or browse plans without logging in.)

Healthcare.gov offers “filtering” so you can look at plans that only meet certain criteria. As a licensed health insurance advisor, my ideal search/filter where I start for my clients is this.

  • PPO, HMO or both

  • Silver or Gold level

Then I look for a reasonable premium with a lower deductible and a plan that offers copays for doctor visits.

Review plans available to you and after you’ve found the best fit for your personal needs, select the one you would like to enroll in and follow the prompts to complete the application process. There will be much more information required at this point depending on the plan you choose.

Be informed and look deeper into the plan, especially if you know you’ll need medical services this year. You can go to the plan details section and see a lot more info. Medical services to consider:

  1. Maternity: Are you planning a pregnancy this year? What does that coverage look like?

  2. Specialty medicine: Do you take a name brand prescription? What is the monthly cost for you on this? The quick snapshot of all of the plans will highlight the generic prescription coverage, but not the name brand. If you require a specific brand name prescription, go to the details of the plan and make sure it’s covered.

  3. Surgery: Planning a knee replacement, tonsillectomy, gallbladder removal? Make sure you look into the inpatient and outpatient surgery benefits of the plans you’re considering.

  4. Other kinds of physicians: Chiropractors and urgent care often fall under different categories outside of primary and specialist doctors. If you like to use these services, look at the details section  to see what that plan will cover.

Congrats! You’re covered. Your new coverage will officially start on January 1, 2019 but note there is a 30 day waiting period before you can use coverage. So hold off on making any doctors appointments until the at least February 1 if you can.

Also remember that if you don’t have an employer or ACA coverage in 2019 you will no longer be subject to the tax penalty when you file your taxes in 2020. So if you don’t find a plan you love or think is a good fit, there is no longer a penalty for looking for alternative healthcare.

Overall, Healthcare.gov does a good job of trying to make it simple to understand all of the plans, but not every plan is created equal and not every plan is right for you and your family. If you still have questions or need assistance finding the right Marketplace plan for you and your family, feel free to reach out to me or another licensed health insurance advisor who can help you with this process.


JENNA LACY IS A LICENSED HEALTH INSURANCE ADVISOR WHO SPECIALIZES IN PROVIDING HEALTHCARE TO FREELANCERS AND THE SELF-EMPLOYED. CONNECT WITH JENNA ON LINKEDIN OR EMAIL HER DIRECTLY TO DISCUSS YOUR PERSONAL HEALTHCARE QUESTIONS AND OPTIONS.