Taxes, physical exams, and oil changes are a few of the items adults have on our “To Do” list each year. But we should add one more item: Review your health insurance options.
Under the Affordable Care Act (ACA), the health care law signed by President Barack Obama in 2010, Americans have more options for health insurance and consumer protections than ever before. But few of us are ever taught how to compare your health insurance options and pick the right health insurance plan.
What are Marketplace Plans?
The ACA created the state health insurance marketplaces (aka exchanges). A lot of confusion exists about the marketplaces. Many people mistakenly believe the marketplace plans are government insurance. They’re not. Private health insurance companies sell their plans through the marketplace. Most states access their state’s health insurance marketplace through www.HealthCare.gov. And 15 states run their own state marketplace.
Why Buy a Plan in the Marketplace?
So why, then, would someone buy a plan through the marketplace instead of just going directly to the health insurance company?
Buying health insurance through the marketplaces offers several benefits:
- Every plan must offer comprehensive coverage of essential health benefits, such as hospitalization, prescription drugs, and mental health care.
- Companies must provide information about each plan in a standardized format called the summary of benefits and coverage (SBC). Because every SBC has the same format, it makes it easier to compare choices.
- Marketplace plans have standardized levels of coverage: platinum, gold, silver, bronze and catastrophic. The difference between these plan levels is the amount of money that consumers pay out of pocket for their health care costs (i.e., cost sharing).
- Consumers may be eligible for financial assistance based on their household size and income level (i.e., premium tax credit and/or a cost-sharing subsidy).
For more information about marketplace plans, visit https://TriageCancer.org/QuickGuide-Marketplaces.
What is Open Enrollment?
You can only buy a policy through the marketplace during the annual open enrollment period, which is generally between November 1 and January 15. However, dates may vary by state.
Some states may have a longer open-enrollment period. For the latest information, visit https://triagecancer.org/ health-insurance-state-laws.
When Will the Plan Start?
Because these are calendar-year plans, coverage will not start until January 1 for people who sign up by December 15th, so make sure you have some other type of coverage until then.
What is a Special Enrollment Period?
The only way to purchase a marketplace plan outside of open enrollment is if you experience a life-changing event, such as losing your job, getting married, or moving to a different state. In those instances, a special enrollment period gives you 60 days to shop for and buy a marketplace plan.
Why is it Important to Compare Your Health Insurance Options During Open Enrollment?
Even if you already have a health insurance plan that works for you right now, it’s always still a good idea to investigate and compare your health insurance options for the next year. In the marketplace, plans change every year. There may be different monthly premiums, out-of-pocket costs, provider networks, or drug formularies. Don’t assume that your plan will stay the same each year.
Also, shopping around can’t hurt, even if you have health insurance coverage through your employer. You can compare what your employer offers to plans sold in the marketplace.
By taking the time to compare your current plan with new options, you may find a cheaper plan or discover that you qualify for other benefits, like financial assistance to help lower the cost of your plan.
What the Key Things to Find Out When You Compare Your Health Insurance Options?
- What is the monthly premium?
- How much is the deductible?
- What is the out-of-pocket maximum for the year?
- Are my health care providers included in the plan?
- Are my prescription drugs covered by the plan?
How Do You Figure Out the Cost of a Health Plan?
To calculate the true cost of a health insurance plan, multiply the monthly premium by 12 to get the yearly cost and then add it to the out-of-pocket maximum. The total is the most you will pay for the year to get in-network, covered health care services.
Where to Go for More Information?
If you feel confused or overwhelmed, you’re not alone. Numerous studies show that most Americans do not understand their health insurance. And to make things more complicated, things are frequently changing at the state and federal levels and people often don’t know where to turn for reliable, unbiased information. Triage Cancer can help.
For more information on navigating health insurance options and how to use your coverage effectively, visit https://triagecancer.org/healthinsurance.
About the author and Triage Cancer
This post was written by Joanna Fawzy Morales, Esq., a cancer rights attorney, author, speaker, and CEO of Triage Cancer. Ms. Morales has spent more than twenty-five years working on behalf of individuals with cancer. She co-authored the book, Cancer Rights Law, for the American Bar Association and has presented nearly one thousand educational seminars on employment, insurance, health care, and advocacy issues for individuals diagnosed with cancer, caregivers, health care professionals, advocates, lawyers, employers, and the general public.
Triage Cancer provides free information about the legal and practical issues that may impact individuals diagnosed with cancer and their caregivers through events, materials, and resources. Triage Cancer also offers CancerFinances.org, a toolkit to help people navigate their finances after a cancer diagnosis.
NOTE: I updated this post on 1-13-25.
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