Choosing the right health care coverage is an important decision. Before you choose a plan, consider these tips:
- Make sure the plan will meet your health care coverage needs – think about how often you see doctors and specialists. What prescription medications do you take?
- Please check the provider directory to see if your current providers are in the network before deciding to enroll.
- Figure out your family’s budget for coverage – some people would prefer to pay more in premiums each month and less out of pocket each time for services like doctors’ visits or lab work. Plans may offer different deductible, coinsurance and copay options so you can choose the level of cost sharing that best meets your health care coverage needs and budget.
- Metal tiers are used to describe the richness of the benefits in each individual plan. These tiers are based on the percentage the plan pays of the average overall cost of providing essential health benefits to members. (It’s important to note that the metal tiers reflect what the plans will pay on average. These percentages are not the same as coinsurance, which calls for an individual to pay a specific percentage of the cost of a specific service.)
- Platinum plans are the most generous and more expensive. These are designed to pay as much as 90 percent of medical expenses.
- Gold plans are designed to pay 80 percent of medical expenses.
- Silver plans are expected to pay 70 percent of medical expenses.
- Bronze plans are expected to pay 60 percent of medical expenses.
- Individual insurance policies may be purchased through an exchange or “marketplace,” or they may be purchased outside of the exchange or “off-market.” Regardless, policies must cover the same set of Essential Health Benefits as mandated in the Affordable Care Act.
The essential health benefits include:
1. Ambulatory patient services
2. Emergency services
4. Maternity and newborn care
5. Mental health and substance abuse disorder services
6. Prescription drugs
7. Laboratory services
8. Preventive and wellness services
9. Pediatric services
10. Rehabilitative and habilitative services and devices.
• You may be eligible for government subsidies to help pay for premiums. Subsidies are available only for coverage purchased through the exchange. Subsidies are calculated based on the modified adjusted gross income for the year and the household size. Subsides may be available to you if your income is between 100 percent of the Federal Poverty Level (FPL) and 400 percent of the FPL. Individuals who qualify for a subsidy must apply for coverage at www.healthcare.gov.
• Enrolling in coverage outside of the open enrollment period (which takes place in the fall) generally requires that you have a qualifying life event that triggers a special enrollment right. A qualifying life event is typically marriage, divorce, birth or adoption of a child or a change in income, among others. It is not a voluntary loss of employer coverage. Documentation of the qualifying event is to be provided at enrollment.
• Pediatric dental is required by the ACA for anyone under age 19 (not included in the quotes). You may request waiver of pediatric dental if you are a dentist providing services to your family or with confirmation from your office that these services are provided to you and your family as an employee of their practice.
• Health Savings Account (HSA) qualified health plans allow people with High-Deductible Health Plans to pay for current health care expenses and save for future expenses on a tax-favored basis. Even if you change jobs or retire, your HSA deposits earn tax-free interest and carry over from year to year. Because HSA-powered health plans cost less than traditional plans, you can use the money you save to contribute to your HSA.
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