Health Care MarketplaceNews & Research

How to Choose a Health Insurance Carrier

Choosing a health insurance carrier in the healthcare marketplace can be a confusing and difficult process, especially if you don’t get insurance through an employer and have to rely on other means for coverage. The Affordable Care Act (ACA or Obamacare) opened up access to more options for major medical coverage, but more options can mean a bigger headache when it comes to finding the right health plan. How do you choose a carrier? Where should you even start? Let’s take a look at your options and how to pick an insurance company that’s right for you.

What Insurance Do You Need?

You can’t predict your next medical crisis – oh that we could – but you can prepare for it with proper health insurance. Without any coverage at all, you risk paying all medical bills out of your own pocket. A doctor visit for a minor problem might cost $68 while visit requiring more in-depth care could cost around $234. And these are just the office visits. These costs don’t take into account things like lab testing, imaging services and complex surgery, which could bankrupt the average American family without any savings. Even if you’re healthy, accidents can happen that demand visits to a doctor, emergency room or walk-in clinic.

When looking at an insurance carrier, you want to choose one that offers the coverage you need for you and your family. Consider how likely you are to need routine care as well as emergency care. Families with children, for instance, would need greater coverage since kids are more likely to end up in a hospital with broken bones or suffer a gamut of illnesses during fall and winter. Your insurance carrier should provide good coverage for these expected and unexpected medical costs.

Premiums vs. Out-of-Pocket Costs

One important factor to consider is the premium costs you’ll pay compared to out-of-pocket expenses. Private health plans might have lower premiums, but they could have high deductibles and copays to compensate. A policy that has higher out-of-pocket costs could mean that a minor illness will result in you paying most of the charges out of your own pocket with insurance covering very little. Once your deductibles are met, the insurance begins paying, but it could take some time to reach that deductible.

Higher premiums mean lower out-of-pocket costs, so keep this rule in mind when shopping for coverage. Carriers set pricing using their own formulas, and it pays to compare cost details. Read the plan overview and ask questions if you’re not sure how a company structures its pricing. You don’t want to get stuck with a low-cost plan if it doesn’t cover anything you need.

Company Reputation

All companies that sell insurance are strictly regulated by the state in which they’re licensed to sell. Any carrier selling health plans in the Obamacare marketplace for 2019 must meet certain criteria. But not all companies have the same level of service when it comes to handling claims, answering questions or addressing concerns. Accidents and illnesses always seem to happen outside regular business hours. This means you may need to reach someone on a weekend or late at night for questions of coverage and benefits. Make sure the carrier you choose has flexible hours and can be reached when needed.

You also want to verify that claims will be paid on time. Until the insurance company pays, you’re responsible for the bill. If payment runs 30, 60 or 90 days late, you could face collection activity from the healthcare provider. The National Committee for Quality Assurance (NCQA) provides a database of insurance carrier ratings that allows you to research information on the carriers in your state.


Appeals Process

At some point, you may have a claim that gets denied by the insurance company. It could be an emergency room visit that the company determines was not an emergency or a claim that was improperly coded by the doctor. When this happens, you may need to file an appeal with the carrier. Companies handle this process in different ways. Choose a health insurance carrier that makes the appeal process simple and applies the process fairly. One way to be sure claims will be handled as you expect is to read the fine print in your policy to confirm that you have the right coverage. Small loopholes in wording could lead to claim denials that will also be denied on appeal.

Coverage Offered

Once you’ve narrowed down your search to a few different carriers with a strong reputation, you want to determine which companies offer the coverage that best suits your needs. You’ve got more options for health insurance in 2019 than you did last year, thanks to some changes from the Trump administration. Major medical coverage will continue to cover 10 essential health benefits, so know that any ACA-compliant plan available today will include a bevy of benefits that could work for you.

If you don’t need or want, or can’t afford, major medical insurance, new regulations make it easier in most states to buy short term health insurance that lasts up to 364 days and can be renewed for up to 36 months. Consider your health needs carefully before forgoing major medical, though. Short term coverage doesn’t work for everyone, and there are plenty of good reasons to buy traditional health insurance.

When comparing insurance carriers, note the benefits that are important to you – like maternity care or prescription drugs – and see how each company handles those benefits. One may provide more generous coverage, or one might require less cost-sharing on your part. If several carriers offer the same level of coverage for the benefits that matter most to you, then choose the company with a better reputation for these services.

Pre-Existing Conditions

Under Obamacare, health insurance providers are required to cover pre-existing conditions as part of major medical benefits. This means that if a member of your family suffered an illness or injury at any time in their life, treatment for that condition must be covered in major medical plans offered on and off the marketplace in 2019. We should note that short term health insurance doesn’t have to abide by this rule. But as long as what you’re buying is a major medical policy from a legitimate source, your pre-existing condition – whether it’s acne, high blood pressure or cancer – must be covered by law.


One way that health insurance companies keep premiums low is to require you to use certain doctors, hospitals and healthcare facilities – all part of a “network” of providers. When you’re comparing policies and carriers, pay attention to network limitations. Some plans, like PPOs, allow you to see providers outside the network, but it costs more money and may not be covered as well as in-network care. Other plans, like HMOs, may not cover any out-of-network care. If you have doctors or providers who you see regularly and like, make sure that your insurance carrier covers those providers. If not, you might face higher costs or have to pay the full bill yourself, which renders health insurance useless.

You have lots of options for health insurance, both major medical and short term, and picking a plan from a carrier isn’t always as black-and-white as it could be. But the process doesn’t have to be stressful. With proper planning and careful consideration, you should be able to choose a company that will provide you with the major medical you need at a cost you can afford without any hidden surprises down the road.

How Do I Buy Major Medical Insurance?

Whether you’re a young adult branching out from a family health plan or a working adult new the insurance marketplace, buying major medical insurance is a very important decision. But a combination of complex regulations, government bureaucracy and the large number of options can make the process of buying major medical insurance confusing and difficult. The simple answer of how to buy health insurance is: Shop for a plan, pick one and pay for it.

Unfortunately, it’s not always that black and white, especially since you have plenty of options for healthcare coverage under the Affordable Care Act. Not sure where to start? Here are some things you need to know about buying coverage.

Obamacare 2019

During the last presidential election, there was a lot of talk about ending the Affordable Care Act (ACA), commonly known as Obamacare. After a lot of back and forth in Congress, conservative lawmakers weren’t able to pass any legislation eliminating the ACA for good. That means that for this year and the foreseeable future, Obamacare remains the law of the land for health insurance.

However, some important changes have been made to how major medical plans work that will take effect in 2019. One big difference is that the tax penalty for not holding health insurance (known as the individual shared responsibility payment) will be zeroed out starting January 1, 2019. The mandate to have minimum essential coverage itself still exists, but since there’s no longer a penalty attached to it, it’s going to be even more ineffective at persuading people to buy health insurance than it was before.

The Trump administration has also made changes to short term health insurance plans. While these don’t count as major medical plans and aren’t a good substitute if you need comprehensive coverage, temporary plans serve a purpose in the health insurance industry. Under current regulations, these plans can now last for “less than a year” nationwide, and you can renew them for up to 36 months. Individual states may set tighter limits on short term plans, though.

Before you shop for health insurance on the private market, make sure you exhaust your options for other coverage. Your job may offer a health plan, or you or your children might qualify for your state’s Medicaid program and/or CHIP. We don’t say this to drive you away – we sell health insurance, after all – but to make sure you have a good understanding of what’s out there. Your work-based coverage might be too expensive, or you just might not like the options that you do have. In that case, a private plan could be the solution you’re looking for.

Where to Buy

If you’re not sure how to buy health insurance, then you may also be wondering where to start looking for a plan. You’ve got four categories of options for shopping: a public marketplace, agents or brokers, an insurance company directly or a private marketplace (like ours). We’ll highlight the features of each below:

  • Public marketplace: Also referred to as a “health insurance exchange,” a public marketplace is one created by the Affordable Care Act. Most states use the federal one at, but 11 states and the District of Columbia have created their own state-based exchanges. Government marketplace plans are the only ones that qualify for cost savings, but you don’t actually need to buy them from the marketplace to get the savings. You can use an independent broker, agency or third-party site like this one to buy an on-exchange plan with savings (if you qualify).
  • Agents or brokers: You probably know that insurance agents and brokers exist. You might even know one personally. Agents work directly with companies to sell their health insurance plans. Brokers work with more than one carrier, usually. Because agents and brokers represent specific companies, you’re less likely to get unbiased advice from them about carriers they don’t represent. But you can work with these people for free since they get paid from the carriers.
  • Insurance company directly: If you know you want to buy from a company directly, you can do all of the legwork yourself to buy a health plan directly from it. Many have online portals of their own now for consumers to use to shop. Just know that you’re not going to get any information about plans from competitors (naturally) if you go straight to a carrier site to get insurance. You risk missing a better plan if you don’t compare your options from multiple carriers.
  • Private marketplace: Private health insurance marketplaces let you compare different plans from different carriers. You’re reading this article on a private marketplace. The benefit of this approach is that you can see multiple options at once, and there are agents available to walk you through your options. We’re not as independent as the federal exchange would be – since customer service on government marketplaces is not staffed with agents – but we do have extensive knowledge of the industry, and we can help you find the right plan.

Insurers sell plans on and off the marketplace. That’s why it’s important to shop your options. Carriers might have completely different plans on and off the exchange sites, and some could be cheaper or provide better coverage if you shop outside of the exchange. Some carriers choose not to participate on the exchanges at all.

Open Enrollment

You can’t just sign up for major medical insurance anytime. Each year, the open enrollment period gives Americans the chance to enroll in health insurance that complies with the ACA. For coverage starting January 1, 2019, the open enrollment period runs from November 1 through December 15. Outside of this timeframe, you’ll only be able to sign up for major medical plans if you qualify for a special enrollment period, which is based on major life events like marriage, the birth of a child or loss of your job.

Common Insurance Terms

As you start shopping, keep some common insurance terms in mind so you know what you’re seeing. We know these terms can be tough to keep straight. Here’s a refresher:

  • Premium: The amount of money you’ll have to pay each month for your health plan, regardless of whether you saw a doctor that month or not.
  • Deductible: A set amount that you have to pay before an insurance company starts paying its share of your medical costs. Some services, like wellness screenings and other preventive care, don’t count toward the deductible (meaning you won’t need to meet the deductible first before the company covers it).
  • Network: Healthcare providers whose services are covered by insurance. “In-network” means a provider in the network while “out of network” usually means that your insurance won’t cover services from this person/provider (or will cover it at a reduced rate).
  • Provider: Any healthcare person or institution that provides your care; this would include primary care doctors, surgeons, psychologists, physical therapists, clinics and anyone or anywhere else that provides care.
  • Copay(ment): Copays are a flat fee charged for services covered by your health plan. You may have a $20 copay for primary care visits, for instance, or a $200 copay for emergency room visits that don’t lead to hospitalization.
  • Coinsurance: Similar to a copay, coinsurance is a percentage that you and the insurer split for your care. Once you meet the deductible, you might have 30 percent coinsurance, which means that the insurer will cover 70 percent of the bill (after the deductible) and you’ll be responsible for the rest.

This list isn’t exhaustive, of course, but these are common terms that come up when you’re buying health insurance.

Buying Health Insurance

Now that we’ve set you up for buying health insurance, you might still be wondering how you actually go about getting a policy. Well, that’s up to you. You’ve got several options for buying major medical plans. We recommend working with health insurance professionals who can answer any questions that you have along the way. Shopping on a private marketplace (like ours) gives you the chance to see different carriers and plans, ask questions of agents over the phone or online, and buy a plan with confidence. Before you check out your options for coverage, though, make sure you’ve got some basic info available, including:

  • Your name and the names of anyone buying a plan
  • Health information, such as medical problems or prescriptions you take, so you can see the coverage that a plan offers for these services
  • Your income and monthly budget, so you don’t get swayed into a plan you can’t afford

Having your information handy will help you find the right plan – not to mention apply when you’re ready. Don’t wait too long to buy health insurance. Remember that you can only buy major medical coverage during open enrollment, which ends on December 15 in most states.

How Soon Does Major Medical Insurance Start?

Open enrollment gives people a chance to shop for health insurance once a year. In 2018, the open enrollment period for coverage starting next year begins on November 1 and runs through December 15. You have other chances to enroll, though. If you have a baby, get married, lose your job or move, you might be able to enroll in a major medical plan thanks to a special enrollment period. No matter when you sign up, though, coverage doesn’t start right away in the major medical world. (Short term health insurance is a different story.) Not sure when your coverage will start based on when you sign up? Here’s what you need to know.

Signing Up During Open Enrollment

As we mentioned above, the federal open enrollment period for ACA 2019 health insurance runs from November 1 through December 15, a period of about six weeks. Whether you sign up at the very beginning of open enrollment, at the very end or right in the middle, your coverage will go into effect at the same time. All plans bought during this timeframe take effect on January 1, 2019.

If you have a 2018 health plan, that coverage will continue until December 31, 2018, as long as you keep up with your premium payments. Your new plan will take effect as soon as the previous one ends. In fact, if you choose to keep your current policy or you’re automatically re-enrolled, you may not even notice any transition period as you move from one calendar year to the next.

Some states that have their own health insurance exchange sites apart from can (and do) set their own deadlines for open enrollment. Residents of those states may be able to wait until the end of December or January to choose their plan for health insurance in 2019. An extended signup period gives people more time to decide on the health insurance that’s right for them, but it does impact when coverage starts. If you want your coverage to begin on January 1, 2019, you’ll still probably have to buy your plan by December 15, 2018. Waiting later than that will likely push your effective date back to February or even March.

Special Enrollment Period Signups

Experiencing a major life event can give you an additional opportunity to sign up for an Obamacare health plan or switch to a different major medical plan. Only certain life events qualify you for a special enrollment period, however, and your new healthcare coverage won’t begin right away. You typically have 60 days after a qualifying event to apply for a change in health insurance. The sooner you apply, the sooner coverage takes effect.

When does coverage take effect if you buy it during a special enrollment period? It depends. The general rule for special enrollment periods is that your coverage will start either the month after you submit your application or the month after that.

  • If you apply for major medical coverage by the 15th day of the month, your new plan will go into effect on the first day of the following month.
  • If you wait until the 16th or later to apply, your new healthcare coverage won’t begin until the first day of the month after next.

For example, if you submit your request for coverage on April 13, your plan will have an effective date of May 1. However, if you pick a plan on April 17 – just four days later – your health insurance won’t begin until June 1.

This rule applies to many of the circumstances that can qualify for you a special enrollment period. These include getting divorced, experiencing a shift in income that changes your eligibility for premium tax credits, and being released from prison. Keep in mind that for some of these qualifications, you’re eligible for special enrollment only if you already have a health insurance plan that qualifies as minimum essential coverage.

Exceptions to Special Enrollment Effective Dates

Not all special enrollment periods hold to the general rule about effective dates. There are exceptions to the rule, including adding children to your plan and knowing ahead of time about coverage changes.

Adding Children to the Family

Birth, adoption and foster placements allow you to apply for major medical coverage when these events happen even if you don’t already have a major medical plan in place. You have two options to choose from when applying for insurance after adding a child to your home: retroactive coverage or future coverage.

Retroactive coverage can be retroactive to the date that the child became part of your family. If your baby was born on September 2, for example, then you can opt for your coverage to have an effective date of September 2, even if you don’t fill out the application until October 23. Alternatively, the coverage can go into effect on the first day of the month after you submit your application. If you want to keep your current insurance plan for one more month before switching, this could be a better option for you.

Anticipated Changes

Sometimes, you have advanced notice that you’re going to be experiencing a major life event. Moving to a new state or losing job-based healthcare might be something you can anticipate. In these cases, you might also be able to plan ahead for your new insurance coverage. Your special enrollment period will begin 60 days before your change is to take place, and it will close 60 days after the change.

If you sign up for a new plan in the 60 days preceding the event, you might be able to start your new coverage sooner. Your new plan’s effective date will be the first day of the month after which the change takes place.

Waiting until after the change occurs could lead to delays in coverage. Your new plan won’t start until the first day of the month after you buy it.

As an example, let’s say that you move to a new state on August 10. Picking out a new plan before you move means that your coverage will begin on September 1. Selecting your new coverage on August 11, right after your move, would also qualify you for a start date of September 1. However, because you have a 60-day window after the event to sign up for a plan, you could also wait until early October to make your health insurance change. If you don’t sign up until October 3, your plan won’t go into effect until November 1.

When buying a health insurance plan, consider the start date for coverage. Open enrollment runs for about six weeks. If you don’t have coverage when you sign up for a new plan during enrollment, then you’ll have to wait until the new year to use your health plan. In the interim, you might consider short term health insurance to fill the gap while you’re waiting for your health plan to take effect. Signing up during a special enrollment period can be an issue of timing as well, so consider your options carefully as you look for the perfect plan.

Financial Help for Buying Health Insurance

The goal of the Affordable Care Act was to make health insurance more accessible to all Americans. Increasing the affordability of insurance was a large component of that goal. In an effort to bring down the costs of coverage for middle-class Americans, the ACA established financial assistance options to reduce how much you pay in premiums and other costs, like copays and deductibles. If you make between 100 and 400 percent of the federal poverty level (FPL), these cost-reducing programs may help you save money on your coverage.

Advance Premium Tax Credits

About 80 percent of people who buy Obamacare plans on the exchange qualify for advance premium tax credits, also known as subsidies. But these subsidies are not an automatic benefit for anyone who buys a private health plan. To receive subsidies, you must not have access to an employer-sponsored health plan, or your job-based insurance must be deemed unaffordable per the limits set by the ACA.

You also have to meet certain income guidelines. Your modified adjusted gross income (MAGI) must fall between 100 and 400 percent of the FPL, which is calculated by taking into account both your household income and your family size. In other words, the FPL is higher for a family of four than it is for a family of two or an individual.

Contrary to what you might think, you don’t have to shop on a health insurance exchange site to get a tax credit. You can benefit from Obamacare subsidies whether you purchase your insurance directly through the healthcare marketplace or you rely on the assistance of a broker to help you obtain health insurance in 2019. When you apply for your ACA 2019 plan, you will provide information about your income and family size. This information will be used to determine your eligibility for premium tax credits. The subsidy amount for which you qualify will also depend on the cost of the second-least expensive silver health plan in your area. (This is known as the “benchmark plan” and it determines cost assistance for everyone.)

Advance premium tax credits will cover part or all of your monthly premium costs. The federal government will submit your subsidy directly to your insurer. Each month, you’ll be responsible for paying the remaining portion of your premium.

You aren’t required to use your full tax credit each month. In fact, you can opt to pay your full premium each month instead of claiming any advance premium tax credit. Any funds that weren’t applied to your major medical premiums will be returned to you in your tax refund the following year.

We want to emphasize the importance of knowing your income or, in the case of self-employed or freelance workers, knowing how to estimate it correctly. If you get a subsidy but end up earning more than you thought for the year – thus reducing the amount of cost assistance that you qualify for – you will owe the difference back when you file your taxes for the year.

Cost-Sharing Reductions

Some people qualify for both ACA subsidies and an additional type of assistance known as cost-sharing reductions. This additional Obamacare benefit is available to individuals and families whose household income falls between 100 and 250 percent of the FPL. You can receive this benefit only if you purchase healthcare coverage at the silver level. As with ACA subsidies, you won’t qualify if you have access to affordable job-based insurance.

Cost-sharing reductions aren’t contributions to your premium payments. Instead, they’re payments made on the part of insurance companies to reduce your personal responsibility for healthcare expenses. This is accomplished by increasing the actuarial value of the plan. The actuarial value for which you qualify depends on your household income.

  • Incomes above 250 percent of the FPL do not qualify for cost-sharing reductions. Silver plans at this level have an actuarial value of 70 percent.
  • Households with incomes between 201 and 250 percent of the FPL qualify for plans with actuarial values of 73 percent.
  • Individuals and families with incomes between 151 and 200 percent of the FPL can purchase silver plans with actuarial values of 87 percent.
  • Those with incomes between 100 and 150 percent of the FPL can benefit from plans with actuarial values of 94 percent.

Not sure what any of that means? It boils down to value. If your income qualifies you for cost-sharing reductions, then you’ll qualify for a health plan with better actuarial value (meaning it covers a greater percentage of your healthcare costs) for less money than the average person would pay for the same plan. And the “discount,” so to speak, is automatic based on your income. The insurance company takes care of it because they’re required to under the ACA.

The federal government used to reimburse health insurers for the expense of these benefits, but that stopped in 2017. The year before, a challenge to cost-sharing reduction payments (how insurers got reimbursed for discounting their plans) had been successful in halting payments based on questions of legal funding, and the Trump administration decided last year to stop them altogether going forward. Insurers responded by raising the cost of their plans – particularly silver-level plans since these are the benchmark for cost assistance – to make up for this loss of reimbursement. Of course, this increased advance premium tax credits across the board since cost assistance goes up with premium prices, so the government is still footing the bill for cost-sharing reductions.

Unlike with premium subsidies, if you underestimate your income when applying for Obamacare 2019, you won’t end up having to pay back any benefits provided to you through cost-sharing reductions.

Lower Out-of-Pocket Maximum

The federal government sets guidelines for how high a major medical plan’s out-of-pocket maximum can be each year. This is the highest amount of money that you can be required to pay for covered healthcare services in a calendar year; it does not include premium costs. Federal limits on out-of-pocket maximums are lower for people who qualify for cost-sharing reductions.

In 2018, the government set a cap of $7,350 for out-of-pocket maximums for individual plans and $14,700 for family plans. This applies across all tier levels. But there are lower limits for people who get cost-sharing reductions. If you earn between 100 and 200 percent of the federal poverty limit, your cap will be $2,450 for an individual plan (doubled for families). Those earning between 201 and 250 percent of the FPL get capped at $5,850 for individual plans and twice that for families. To reiterate, cost-sharing reductions are only available at the silver level.

Other than setting limits on out-of-pocket maximums, the federal government does not specify what an insurer must do to increase the actuarial value of a plan purchased on the marketplace in 2019. Carriers might charge lower copays and coinsurance rates while charging a higher deductible to make the math work out on actuarial value.

Lower-Income Options

Advance premium tax credits and cost-sharing reductions are available to you only if your household income is at least 100 percent of the FPL. If your income is lower than that, you won’t qualify for the help. In some states, you might qualify for Medicaid instead. Since the ACA became law, most states have expanded their Medicaid programs to include higher income parameters and a broader applicant base.

However, some states have chosen not to expand Medicaid. If you live in one of the states that opted out of expansion, you may not qualify for this government-assistance program, even if you have a low income. People who don’t make enough to qualify for ACA assistance but who make too much to be approved for Medicaid are said to be stuck in the Medicaid gap.

Buying full-price major medical insurance might be an unrealistic prospect if you’re stuck in the Medicaid gap. Instead, you might need to rely on receiving healthcare services from free or sliding-scale clinics. And if you need coverage for emergencies in the interim, short term health insurance offers an affordable safety net.

The ACA sought to make health insurance more affordable, and for many people, it accomplished that goal. If you’re still unsure about your options or where to get started, let us help. Asking questions and exploring the plans that are available to you – on and off the exchange – is the only way to know for sure how to afford health insurance in 2019.

More Than Cost: What to Consider When Buying Health Insurance

If you’re looking for the best type of health insurance in 2019, consider more than the cost at face value. Competing plans may seem alike, but the fine print will show how much an insurer covers for things like hospitalization, prescription drugs and lab work. When it comes to the real cost of health insurance, you may be faced will bills topping five figures or more even with coverage. Look beyond the premium price to see what a plan truly covers – and what your responsibility as a subscriber will be.

The Affordable Care Act (ACA or Obamacare) has been a boon for many people who might otherwise not be able to afford health insurance. It requires some research, though, to figure out the plan that works best for you. Costs will vary widely among plans, even plans offered by the same insurer in the same area. Obamacare requires all major medical policies to cover a set of the same types of services, but not all health plans treat this coverage the same. The premium is only one part of the cost. Copays, deductibles, coinsurance and out-of-pocket caps should also be considered when buying health insurance.

10 Essential ACA Benefits

Major medical plans today must cover 10 essential health benefits as mandated by law. These are types of services. The law doesn’t specify the degree to which a plan must cover the benefits, either, so one plan might require you to pay more for services like physical therapy while another limits prescription drug coverage. Nevertheless, every ACA-compliant plan bought on or off the exchanges will cover the following types of care:

  • Outpatient services
  • Emergency room care
  • Hospitalization
  • Maternity benefits
  • Mental health services
  • Prescription drugs
  • Rehabilitative care and equipment
  • Laboratory costs
  • Preventive care, including screenings and immunizations
  • Pediatric care, as well as pediatric dental and vision care

As you might imagine (and might have noticed), covering all of these services means that health insurance plans today cost more than they used to. Comprehensive benefits help you take care of yourself, but they also make insurance more expensive.

Network Plans

Some health plans rely on networks to keep costs low for subscribers. Health maintenance organizations (HMOs) usually only cover providers that participate in the plan’s network unless it’s an emergency. Preferred provider organizations (PPOs) typically cover both in- and out-of-network care, but non-network care is covered at a lower rate, meaning you’ll have higher costs if you see providers outside the plan’s network.  

Choosing healthcare coverage offered within a network can help with the cost of insurance. Insurers rely on a large market of healthcare consumers participating in the plan. This allows them to negotiate lower physician, hospital and prescription drug prices based on volume. That’s why network providers will rely on capturing a large share of the healthcare marketplace in 2019 to reduce costs. It’s also one of the reasons that an insurer can provide primary care and major medical coverage at reasonable rates.

What About Seeing a Specialist?

Some insurers hold down costs by requiring a referral from a primary care physician before a patient can get an appointment with a specialist. In general, any plan that allows the patient to visit specialists without a referral will require a higher premium. In some cases, it may be worth the savings in premium and copay costs to opt for a managed plan that requires referrals.

This is one of those important details of a health insurance plan that should be considered on an individual basis. Most people rely on their family physician the majority of the time. But for those with chronic conditions, the ability to see a specialist without a referral may be a vital feature of a health insurance plan. If the cost of the insurance is within the family budget, unfettered access to specialists can be an important benefit that’s worth the extra cost per month.

ACA Cost Assistance

Obamacare has built-in discounts for people who qualify based on income, one of those being advance premium tax credits, also called subsidies. If you earn between 100 and 400 percent of the federal poverty level (FPL), you can get a subsidy to reduce your monthly premium. About 80 percent of people who buy plans on an Obamacare marketplace qualify for advance premium tax credits.

For those who qualify for additional assistance, the ACA cost-sharing reduction (CSR) lowers the cost of health insurance deductibles, copays and coinsurance. Over half of those enrolled in a plan receive CSRs, which require enrollment in a silver-level plan. You must earn between 100 and 250 percent of the FPL to qualify. These reductions are available alongside the subsidies, so you can get both if you’re eligible.

Funding Problems

Obamacare has been a game of political football since it became law, escalating more quickly since President Trump took office. You might worry that the ACA’s built-in discounts will be discontinued. Given the conflicting news stories surrounding cost-sharing reduction payments and everything else related to healthcare policy, it’s not surprising that lots of people have lots of questions about where health insurance stands at the moment. In short, it stands where it has since 2010: The ACA is still law.

There have been some important changes, though. While insurers are still required by law to offer cost-sharing reductions to people who qualify for them, the federal government stopped reimbursing insurers for these payments in October 2017. Since insurers now carry the full brunt of reducing costs to consumers, they’ve raised premiums as a result. Silver-level plans got hit hardest since these plans form the benchmark for federal subsidies.  

Higher premium prices really only affect people who don’t qualify for cost assistance since that assistance increases with the price tag of marketplace health plans. For people who don’t get subsidies, though, these price hikes can be devastating.

We should note that families with an income too high to qualify for subsidies may have access to off-exchange silver plans at a lower price. Some insurers have opted to provide the same benefits and protections under ACA-compliant off-exchange plans, but without the increased premiums that reflect the cost-sharing burden.

ACA-Compliant Plans

When looking for health insurance outside of the ACA exchange, know that you can buy major medical coverage that meets the demands of the law and gives you comprehensive benefits. Off-exchange health insurance includes major medical coverage, and it provides the same benefits and protections as on-exchange plans. The difference is that off-exchange health insurance is purchased directly from an insurance company, via a broker or insurer, or through an independent marketplace like this one rather than through a state or federal exchange.

Unless an insurance plan is ACA-compliant, there’s no guarantee that it covers every healthcare need. All major medical plans are now required to conform to ACA guidelines, but some plans – like short term health insurance – don’t count as major medical insurance and don’t fall under that umbrella. In this case, it’s especially important to look at all of the costs of an insurance plan and to read the details about exactly what’s covered.

When scouting for health insurance in 2019, make sure that any plans you consider cover the services that matter to you. A good place to start is the list of 10 essential benefits provided by the Affordable Care Act and to determine whether a health plan you’re considering complies with the law. Beyond the face value of the health plan, look at how it handles your regular out-of-pocket expenses so you don’t get stuck with coverage that doesn’t really cover your needs.

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