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Things to consider before selecting Market Place Health Plans

Plan Category

Market place divide health plans into 4 main categories, Bronze, Silver, Gold and Platinum. 5^th category Catastrophic plan is for people under 30 and some people with limited income

Generally, these categories have differences in the plan’s share and your contribution to the cost of the covered services. The higher the level, the higher the premium and lower cost you pay.

Plan and Network Type

Marketplace offers several types of health insurance plans to cater to the needs of the mass population. Some plans have restrictions that you can get care from their providers’ network. Others provide flexibility to see doctor of your choice by sharing greater cost for providers outside of network.

Health Maintenance Organization (HMO): A budget-friendly plan

A Health Maintenance Organization (HMO) plan offers lower premiums and deductible but requires using doctors within the HMO Network. You need to choose a primary care physician (PCP) when sign up for the plan. You need a referral from your PCP to see the specialist.

Point of Service (POS): An affordable plan with out-of-network coverage

This plan also requires you to get referral from your PCP but allow you see the Doctor from out-of-network with Higher cost means you pay more.

Exclusive Provider Organization (EPO): A larger network makes life easier

This plan covers only in-network care, but the network is larger than HMO and provide more flexibility they may or may not require referral from PCP. Premiums are higher than the HMO.

Preferred Provider Organization (PPO): The plan with the most freedom

PPO offers greater flexibility in terms of seeing a Doctor out-of-Network without PCP referral. In-network services have lower Copays and coinsurance. Premiums are high,

Coverage and Benefits

It is recommended that must review the coverage of the plan considering personal and family members’ anticipated health needs like pregnancy, existing conditions, symptoms and other chronic conditions. Also consider the family medical history, which will help you to get regular tests and checkups to monitor your health.

Premiums

Everyone must choose the plan based on their affordability, it is very important because if you missed 3 premiums, your policy will be terminated, and it is become difficult to reinstate.

Deductible/Coinsurance/Out of Pocket Max

It is an important factor that needs to be considered while reviewing any plan, it gives you an idea of the expense you need to bear in case you use insurance. Below is an example of insurance cost you may need to pay.

Copayment/Copay

It is a fixed amount paid by patient to a health care providers for the covered services, for example PCP visit you may pay $10 etc.

Check your doctor is in Network

You must confirm that your doctor is accepting the plan before sign up for the plan, if your PCP or any specialist you currently under his treatment will not in network you may not covered or need to share high cost.

Quality Rating

Marketplace provides a star rating for the plans on a scale of 1-5, which provides better understanding of plan performance in general.

Premium Tax Credits

A part of the premium that will be paid by the government to lower your monthly premium based on your income estimates and household size and information.

Cost-sharing Reductions

This is usually available on Silver category and often called “extra savings” which will discount your deductibles, copayment and coinsurance.

It is also recommended that copays and coinsurance for common services like Emergency Room visit, urgent care, x-ray etc. should be reviewed carefully to avoid higher costs. Also check for waiting time if it is required to cover your existing condition.

It is an important decision, so, it is a wise idea to contact a licensed health insurance agent to get the plan on marketplace who will identify the plans based on your need and provide you the con and pros of the plan. Kindly note that after the Marketplace Enrollment Period you are not allowed to change the plan and need to wait until the Enrollment Period begins next year.