The Affordable Care Act (ACA), sometimes known as Obamacare, was enacted in 2010 to expand access to health insurance. It created the Health Insurance Marketplace where individuals and families can buy health insurance if they don’t have access to other coverage such as employer based insurance or Medicare. In 2024 more than 21.4 million people enrolled in a plan through the Marketplace. Here’s what you need to know about how to buy insurance through the Marketplace.
To be eligible you must:
- Live in the U.S.
- Be a U.S. citizen or national or be lawfully present
- Not be incarcerated
- Not be enrolled in Medicare
Every state has an official Marketplace, operated either by that state or the federal government. In Texas, residents can purchase ACA plans through HealthCare.gov. The Marketplace consists of plans offered by multiple private insurers. You cannot be denied coverage for pre-existing conditions. Plan benefits and costs can vary greatly between insurers and plans.
All plans offered on the Marketplace must include the 10 Essential Benefits:
- Hospitalization
- Ambulatory services (doctor visits and outpatient hospital care)
- Emergency services
- Maternity and newborn care
- Mental health and substance abuse treatment
- Prescription drugs (drug formularies vary between insurers so be sure to know how your medications are covered before enrolling in a plan)
- Lab tests
- Pediatric services for children including dental and vision care
- Rehabilitative/habilitative services and devices
- Preventive and wellness services including chronic disease management
Depending on your income you may qualify for a premium tax credit that lowers your monthly premium or provide savings on your out of pocket costs.
Understanding Metal Levels
ACA plans are divided into four different metal levels, Bronze, Silver, Gold, and Platinum. There is also a separate level for Catastrophic coverage. The difference between the levels is in the cost sharing, or how much you pay out of pocket before your insurance kicks in.
- Bronze- lowest monthly premium and highest out of pocket costs
- Silver- moderate monthly premium and moderate out of pocket costs
- Gold- high monthly premium and low out of pocket costs
- Platinum- highest monthly premium and lowest out of pocket costs
- Catastrophic– low monthly premium and very high deductibles. Catastrophic coverage serves as a safety net for worst case scenarios. Most routine medical expenses are not covered. It is available to those under 30 years of age and individuals of any age who qualify for a hardship exemption (when Marketplace or job based insurance is unaffordable). If you don’t qualify for Catastrophic coverage, you will not see it displayed as an option when shopping on the Marketplace.
The right level choice for you will depend on how healthy you are, how often you use medical services and what you can afford. If you are relatively healthy and don’t see the doctor often, a bronze plan might be right for you. If you have a chronic health condition and you see doctors often and take a lot of medications, a higher metal level might be the better option.
Types of Plans
In addition to choosing a metal level, you will also be able to choose from different plan designs such as HMO, POS, and PPO. The type of plan will determine if you have any out of network benefits and what you will pay for those benefits. Since each insurer’s provider network is unique, if you want to see specific doctors and hospitals for your care, it’s important to check the network before choosing a plan. Plans offering out of network coverage usually cost more.
- HMO- limits care to doctors within the insurance carrier’s network. Usually only emergency rooms and urgent care are covered out of network.
- POS- you pay lower costs when you use in-network providers. You may need referrals or prior approval to see doctors outside the network.
- PPO- allows the flexibility to use providers both in and out of the plan’s network, but you will pay more for out of network care.
ACA Open Enrollment
ACA Open Enrollment occurs each year from November 1st through January 15th. If you enroll by December 15th your coverage will be effective on January 1st. If you enroll by January 15th your coverage will be effective February 1st. If you have a monthly premium, you must pay the first month to activate your coverage.
You can enroll outside of Open Enrollment if you qualify for a Special Enrollment Period due to certain life events such as losing health care coverage through an employer (or Medicaid or CHIP), moving, getting married, divorced, having a baby or adopting a child. Changes in income may also qualify you for a special enrollment period.
How a Licensed Agent Can Help
Finding the right plan can be challenging but you don’t have to navigate the Marketplace alone. There are many benefits to working with a local, licensed agent in your area:
- Agents who sell insurance through the Marketplace must be licensed and certified
- They are familiar with the plans offered in your state and the enrollment process
- They can help you find the plan that meets your specific health care needs and your budget
- They can help you avoid any gaps in coverage
- They can help you determine if you qualify for a premium tax credit
- It does not cost you anything to work with an agent
The experienced team at Healthcare Educators can show you all your options and help you compare a variety of plans.
Contact us today.