Knowing that your healthcare costs are covered for the year ahead can be a big relief. Thankfully, millions of Americans have access to health insurance through the Affordable Care Act (ACA). The ACA’s Health Insurance Marketplace lays out your health insurance options so you can shop for a plan that best fits your needs.
A new funding boost through the American Rescue Act has made finding a plan even easier. People who are hunting for healthcare can find more plans for less money through federal and state marketplace insurance options.
So with more health plans than ever to choose from on the Affordable Care Act Insurance Marketplace, how do you make sure you’re purchasing the right one? That’s where licensed insurance agents come in. They’re trained professionals who help you find a plan and complete the entire enrollment process—at no cost to you.
You can also get help from a navigator, who has some insurance training but is not a state-licensed agent. However, navigators are not allowed to make plan recommendations, whereas agents can assess your specific health needs, and budget and make suggestions tailored to your situation.
“When it comes to protecting your family and your health, it’s good to get all the help you can,” says Brett Casey. He’s a licensed insurance agent with HealthMarkets in Yukon, Oklahoma. “At HealthMarkets, we have access to more than 300 insurance companies. Our job is to find the plan that fits your needs and your budget—period.”
Ask your agent these nine questions to help them do just that.
1. Why would I want a Marketplace plan?
You could save big on healthcare coverage. “The majority of Americans in the country shopping for plans qualify for a subsidy [for an ACA plan] to help pay for their health insurance,” says Casey. Subsidies are monthly credits based on your income that reduce a plan’s premium costs.
But don’t think subsidized insurance is inferior. “It’s good coverage,” says Casey. “It covers any preexisting conditions, mental health, even maternity care.” You also may have health insurance options from big companies. “The only difference is that through the ACA, your premiums could be more affordable,” he says.
2. How does shopping on the marketplace work?
In most states, the ACA marketplace is run by the federal government, while other states may run their own via a different site.
Although plans are available through these federal and state marketplaces, you can also find them by shopping with an insurance agent (like one available via HealthMarkets).
Other options could include visiting an insurance aggregator or cluster, which is a website that offers customers access to a network of independent agencies that combine premiums; or simply contact a health insurance company directly.
3. Will I qualify for a subsidy, and if so, how much?
That depends on your income and tax filing status. “For people who meet income guidelines there’s financial help available,” explains Casey. You may qualify for lower monthly premiums or savings on out-of-pocket costs.
Whether you speak to an insurance agent or apply online, you’ll be asked some basic questions about your anticipated income for the following year. Have your most recent tax return on hand to use as a guide. (Self-employed? You’ll need to make a good-faith guess based on your most recent earnings. A quick conversation with your accountant can help.)
Four out of 5 people enrolling in a federal marketplace plan for 2022 coverage will find one for $10 or less per month, according to the Georgetown University Health Policy Institute. And many will pay no premiums Even people who earned 400% above the federal poverty level in 2021 (that’s $87,840 for a family of three) may qualify for a subsidy.
(Related reading: This is how ACA subsidies work.)
4. How much healthcare coverage do I need?
It depends on your health needs and your budget. Still, it can be tricky to anticipate what’s to come. “Nobody has a crystal ball, but it’s important to find a plan that’s based on realistic expectations about your health,” says Casey.
Your insurance agent can talk with you about the pros and cons of each plan level. In general, marketplace plans are divided into four metal categories.
- Bronze plans tend to have the lowest monthly premium But those savings come with higher deductibles and copays or coinsurance. Plans with copays have a set fee for specific medical services, such as doctor visits, prescriptions, and lab work. For plans with coinsurance, your insurance pays a percentage of your expenses and you pay the rest.
Don’t forget to estimate what your maximum yearly out-of-pocket expenses might be before choosing a plan. “If you’re pretty healthy and only see the doctor once or twice a year, a bronze plan may be a good choice,” says Casey.
- Silver and gold plans have higher monthly premiums, but lower copays and deductibles. “If you’re planning to have a baby next year, or if you’ve got kids who play sports, or if you think you might need surgery, consider a silver or gold plan,” suggests Casey.
Have a chronic condition like diabetes or cancer? You may need a silver or gold plan to help cover continuing treatments.
- Platinum plans tend to have the highest monthly premiums. But these plans also pay the largest share of your medical costs (meaning you’ll spend less out of pocket). If you’re expecting to need a lot of healthcare in the coming year—and would rather pay more per month than worry about what might amount to large out-of-pocket expenses—this plan type may work for you.
5. What if my medical needs change?
You can always change to another plan next year during open enrollment—which begins November 1—or if you have a qualifying life event, such as a job loss or a move.
“You can go from bronze to gold or even platinum, and they can’t say no,” says Casey. “Open enrollment comes up every year, so you can switch back and forth. Pre-existing conditions are always covered, so you could be going through cancer treatment, and they can never turn you down.”
6. Will my favorite healthcare providers be covered?
If you have a preferred healthcare provider that you really want to stick with, call their office or visit their site to find out if they’re in the network of the plans you’re considering. Insurance companies put together networks of providers who agree to charge certain rates for their services.
If you go out of network, you can wind up paying a whole lot more. Check the plan information on the insurance company, or ask your agent. And if you have a preferred hospital, do the same.
7. What about my prescriptions?
If you have a chronic condition, you may be taking several different prescriptions—and they could be very expensive. When choosing insurance, check the formulary, which is the list of drugs covered by each specific plan. “Make sure your medications are covered,” says Casey. “Or you could be looking at some very big bills.”
8. Should I consider an HMO or a PPO plan?
If you’ll be traveling a lot—or you want the biggest choice of providers possible—you’ll want a plan with some flexibility. A smart choice is a Preferred Provider Organization (PPO) plan, says Casey. In a PPO plan, you have a network of providers, but you also have the freedom to visit any healthcare provider you wish.
That’s different from a Health Maintenance Organization (HMO) plan, where you often need referrals from your primary care provider to see in-network specialists.
No matter what kind of plan you have, you’ll still be covered for emergencies when you travel or are out of network. “If you live in Texas and you go skiing in Colorado, you’ll still get out-of-network emergency treatment if you break your leg on the slopes,” Casey explains.
And if you’re traveling internationally, you may want a separate insurance policy. “At the end of the day, you’ll enjoy your trip more if you know you’re protected if you get sick or injured in a foreign country,” says Casey.
9. Where do I turn if I need more help?
You can call or text your insurance agent anytime and with any questions or problems. “It’s so much easier than calling an 800 number,” says Casey.
Ready to get started? If you’re in the market for a new plan, HealthMarkets can help you find health insurance at no cost to you. Start reviewing your options online today, or call (800) 304-3414. to speak with a licensed insurance agent.