It’s time to start thinking about your health insurance needs again!

The Affordable Care Act requires all U.S. citizens (with certain narrow exceptions) to have health insurance or pay a fine. If you don’t have coverage through an employer-sponsored plan or a government program such as Medicare or Medicaid, you can buy coverage for 2017 during the annual open enrollment period from now through Jan. 31, 2017.

You have choices and it might be tempting to just choose the least expensive plan. There are, however, other considerations you should take into account.

Individuals can purchase health insurance from the Marketplace Exchange created by the Affordable Care Act, a private exchange or a private health insurer.

Where to Buy Coverage?

The types of plans available to you and the price you pay may depend on where you purchase your coverage. If you might qualify for a subsidy, you’ll want to shop on the Marketplace Exchange. You can only receive a subsidy by shopping the Exchange, however, you may be able to find insurance that’s less expensive even without the subsidy.

To shop on the Exchange, go to Healthcare.gov and enter your ZIP code. You’ll be sent to your state’s exchange if it has one. If not, you’ll use the federal website. You can also contact our office—as licensed insurance professionals, we can help understand the various types of plans and costs involved, and help you secure coverage. Insurers pay us for our services, which cost you nothing extra.

When you buy coverage through the Exchange, you will pay a monthly premium to your insurance company. You also pay out-of-pocket costs, including meeting the deductible required by the plan you chose.

Plans on the exchange are divided into four “metal categories” — Bronze, Silver, Gold and Platinum. Plan categories have nothing to do with quality of care; they simply indicate the coverage levels. You’ll pay the lowest premiums for a Bronze plan, but when you have a claim, the Bronze plan will require you to pay more out-of-pocket for covered health services.

Compare Insurance Plans

You’ll get the most information about a plan from the summary of benefits. One of your first steps should be to look at your family’s past medical history to determine the level of care you’ll need in the future. Do some family members suffer regularly from severe allergies? Does someone in your family have diabetes or do you know of an upcoming surgery? Any indication that you’re going to need regular access to a doctor is a good sign that you should consider plans that cost more now but will cover more of your medical costs later.

Every plan also has its own level of out-of-pocket costs, which are the costs you will pay after the insurance company pays its portion. Each plan also will have its own deductible — the amount you have to spend on out-of-pocket medical expenses before your insurance pays.

There are four types of insurance plans. Whether you buy coverage on or off the Exchange, you’ll encounter these same basic types of plans. The one you choose will help determine your out-of-pocket costs and the doctors you can see.

 

• Health Maintenance Organization (HMO): Lower out-of-pocket costs and access to a primary doctor; focuses on integrated care — particularly prevention and wellness; you must seek care from a provider who is in the network, except for emergencies.
• Preferred Provider Organization (PPO): You don’t have to stay in network and use the doctors and hospitals that are in the PPO network, but care will be less expensive if you do; you don’t need referrals for care.
• Point of Service Plan (POS): In-network care is less expensive, but you have to get a referral from a primary doctor to see a specialist.
• Exclusive Provider Organization (EPO): Lower-out-of pocket costs; you have to stay in network except for emergencies; you don’t need referrals for care.

 

You can also buy coverage through a private exchange or private insurer, which will provide insurance coverage for a premium. If you don’t qualify for a subsidy (and even if you do), you might find coverage more affordable through a private insurer.

The Importance of Networks

If you have established relations with certain doctors or healthcare providers, you’ll want to check the plan’s list of approved healthcare providers. Is your doctor included? Plans that feature a network usually offer lower costs because the insurance company has signed an agreement with certain providers to provide lower rates. Your insurance provider will provide a list of doctors who have been approved for the plan.

Something else to consider: Do you like going to see your doctor for a referral before scheduling a procedure or visiting a specialist? This is something an HMO or POS will require. Some people don’t mind and like the idea that their doctor’s staff will coordinate the visit and send their medical records to the specialist.

We can help you evaluate your options—please contact us for more information.

Do you qualify for a subsidy? Health insurance subsidies—which are actually premium tax credits—help eligible individuals and families with low or moderate income afford health insurance purchased through a Health Insurance Marketplace. To get this credit, you must have an income no more than the federal poverty level and file a tax return.

The poverty level varies with your location and family size. Healthcare.gov offers an easy-to-use tool that lets you see whether you are eligible.