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Choosing a plan

Choosing the right health plan can be confusing at times. But, you don’t have to figure it out on your own. You may still explore your coverage options on the Marketplace after the Open Enrollment Period. And if you’ve had a “qualifying life event,” which is a change in your situation, you may be able to enroll in a Marketplace plan through a Special Enrollment Period.

Below are some educational tips to consider when choosing a plan that works for you and fits your budget.

You can also click here to find a specially trained Navigator in your community, who can talk to you in person or on the phone for free about your coverage options and help you enroll.

Plan Categories

When you shop for plans through the Marketplace, there are different plan categories based on how you and the plan can expect to share the costs of care. The category you choose affects how much your premium costs each month, the portion of costs your insurance company pays when you use your coverage, and your total out-of-pocket cost.

These amounts are averages and will vary from person to person depending on how much health care they use. In general, the more you are willing or able to pay each time you need health care services, like a doctor’s office visit or prescription, the lower your monthly premium payment will be. The different categories do not mean that some plans are lower quality. All Marketplace plans cover the 10 Essential Health Benefits.

Thing To Keep In Mind

  • Are you in good health? Or, do you have savings you could use for unexpected health costs?
  • How often do you visit the doctor? If your health care needs are moderate, are you concerned about being able to pay for services for an unexpected illness or injury if your plan has high out-of-pocket costs?
  • Do you have an illness or see the doctor often? If so, what level of costs are you comfortable paying out-of-pocket?
  • Will you qualify for financial help to lower monthly premium costs or reduce cost-sharing through the Marketplace?
    • Only Silver plans are eligible for financial help with cost-sharing, and sometimes this financial help makes the cost-sharing on the Silver plans lower than Gold or Platinum plans.

Plan Types

Depending on the type of plan you buy, your care may be covered only when you see a network provider. You may have to pay more, or get a referral if you choose to get care from a provider that is not in your plan’s network.

A provider network is a specific list of the doctors, hospitals, pharmacies, and other health care providers that your plan covers. These providers are called network providers or in-network providers. A provider that your plan does not cover is called an out-of-network provider.

  • HMO (Health Maintenance Organization)
      • With an HMO, you may have lower out-of-pocket costs than other plans.
      • These plans generally will not pay for out-of-network services, or have limited out-of-network coverage, except in emergency situations.
      • You will need to pick a regular doctor, called a primary care physician (PCP), who can refer you to see other doctors in your network, like in-network specialists.
    • Covered Providers
  • POS (Point of Service)
      • On average, POS plans have higher out-of-pocket costs than HMO plans but lower out-of-pocket costs than PPOs.
      • Like an HMO, you will need to pick a regular doctor, called a primary care physician (PCP), to help monitor your health care; however, you do not have to get permission before visiting other doctors in your plan’s network, like in-network specialists.
      • POS plans give you the option of going out-of-network for services, but you will usually have to pay more.
    • Covered Providers
  • PPO (Participating Provider Option)
      • PPO plans usually have higher out-of-pocket costs than other plans.
      • With a PPO Plan, your insurance company will pay a portion of your out-of-network costs. This means you will have more freedom to choose doctors and hospitals regardless of network but risk paying more for services provided out-of-network.
      • You do not usually have to pick a regular doctor or get referrals to see specialists.
    • Covered Providers

Thing To Keep In Mind

  • Are your doctors and pharmacy in the plan’s network? Is your preferred hospital in the plan’s network?
  • Where do you generally see the doctor? If you get health services in multiple places or travel often, does the plan cover out-of-network providers or have a national provider network?
  • Will the plan require a referral to see a specialist or get other services? Do you prefer having one doctor who recommends other providers for your total health care?
  • Click here to download more information about plan costs.

Plan Costs

There are two main types of costs you pay for health coverage: monthly premiums, which are monthly payments you make to your insurance company even if you don’t get medical services, and out-of-pocket expenses, which you may pay each time you visit the doctor.

Though the exact amount you pay for health care services depends on your specific health plan, most plans use a combination of these two payment types.

In general, the more you are willing to pay out-of-pocket for health care services, like doctor visits or prescription medications, the less you will pay for your monthly premium.

There are three different kinds of out-of-pocket costs, which you pay when you visit the doctor. Your specific plan could have a combination of the following:

Deductible: Your deductible is the amount you pay before your insurance plan will begin paying for most health care services covered by your health plan. Some health plans will pay for services before you meet the deductible, so it is important to confirm with the insurance company. Click here to learn more about deductibles.

Coinsurance: Coinsurance is a type of cost-sharing where you pay a percentage of the total price for a covered health care service, like a lab test, and your insurer pays the rest. The percentage varies for different health care services depending on the health plan you choose. Click here to learn more about coinsurance.

Copay: Copay is a fixed amount that you pay for health care services covered by your plan, like a doctor visit, usually paid when you receive care. Click here to learn more about copays.

Things to Keep in Mind

  • Generally, if you choose a plan with a lower premium, you will have higher out-of-pocket costs when you receive care. If you choose a plan with a higher premium, you will have lower out-of-pocket costs when you receive care.
  • Consider the health care needs of your household when deciding which Marketplace plan to buy. If you expect many doctor visits or regular prescriptions, you might want to consider a plan with lower out-of-pocket costs.
  • When you complete a Marketplace application, you can compare plans side-by-side based on price and other important features. You can also learn if you can save money on your monthly premium or get lower out-of-pocket costs with financial help.
  • Click here to download more information about plan costs.