If you want your new health insurance to start on January 1st then you must enroll before December 15th. You can still enroll until January 15th, but your policy won’t start until February. We know you’ve been hearing OEP over and over the last few months, but that’s because we can’t stress enough how important it is. Not only is this the only time you can enroll in a new plan. This is the only time you can review your current plan and make sure you have all of the coverage you need within your budget. You’re in control of your health and there’s plenty of plan and carrier options out there ready to help you stay in control.
Guaranteed Coverages
The Affordable Care Act (ACA) brought a lot of change to the health insurance industry. All of which center around making sure everyone has access to affordable coverage. The ACA introduced the “10 essential benefits”. Which are 10 health care benefits that every marketplace plan must cover regardless of tier, plan type, cost, or provider.
Ambulatory patient services
Emergency services
Hospitalization
Laboratory services
Mental health and substance use services
Pregnancy, maternity, and newborn care
Prescription medications
Preventative and wellness services and chronic disease management
Pediatric services
Rehabilitative and habilitative services
Not only are health plans required to cover these benefits. Insurers are also prohibited from denying or charging more for a plan based on pre-existing conditions. So thanks to the ACA you are guaranteed to get a plan that covers all of your basic needs without having to pay an arm and a leg.
Your Options
You’ve got nothing but options during the OEP, from plans to plan tiers to possible subsidies and then some. Let’s go over the basics and give you a good starting point in your search.
The first thing you have to do is choose a plan type. While every Marketplace plan is legally required to cover the “10 essential benefits”. Plans can offer extra benefits and they can all be structured differently. So, this step is a big one because it sets the foundation for the coverage you have.
HMOs offer you the option of choosing from a local network of participating physicians, hospitals, and other healthcare providers and facilities. As part of these health insurance policies, you must choose a primary care physician (PCP) from this network. Your primary care physician (PCP) will get to know you and help you organize all of your medical care. They are also responsible for referring you to any specialists. Without this recommendation, your HMO would not cover a specialist visit. A HMO plan’s out-of-pocket costs are frequently lower than those of other types of health plans as long as you stay in-network. In general, an HMO may make sense if you prioritize lower expenses and don’t mind using a PCP to oversee your treatment.
PPOs offer a vast network of participating providers, so you can choose from a wide range of hospitals, clinics, and healthcare facilities. Unlike HMOs, PPOs provide some coverage for providers outside of their network, but not as much as they would for an in-network provider. Another significant distinction between PPOs and HMOs is that you aren’t required to choose a PCP and you can see a specialist without a referral. A PPO is often a smart option if you want more control over your options and are willing to pay extra for it. It would be especially useful if you travel frequently because you would not have to see a primary care physician.
Exclusive Provider Organization (EPO)
EPOs also allow you to choose from a network of participating providers. Except in cases of emergency, most EPO plans do not cover care outside of their network. As a result, if you see a provider or facility that is not part of the plan’s local network, you will most likely be paying for the whole cost of services. As for PCPs, EPOs can go either way, some require you to choose a PCP and others don’t, it just depends on the insurance company you choose. In either case, as long as the specialist is in the plan’s network, you will not require a referral from your primary care physician. If you need cheaper monthly rates and are ready to pay a larger deductible when you need medical treatment, an EPO plan may be for you.
Point of Service (POS)
POS plans combine the benefits of PPOs and HMOs. A POS’s provider network, like an HMO, is often smaller than a PPO plan, and in-network care expenses are typically lower, as with a PPO. In POS plans, you must select a primary care provider (PCP) from a network of physicians and other primary care specialists. If you need to see a specialist, you have to get a referral from your PCP.
However, just like with PPO, you have the option of seeing in-network or out-of-network experts. However, if you visit an out-of-network provider, your part of the costs will be higher, and you will be responsible for submitting any claims. POS insurance plans are a terrific option for many people, especially if you’re looking to save money and don’t need out-of-network healthcare services. If you are prepared to coordinate your care through a primary care physician, a POS plan may be perfect for you.
Health Expense Accounts
There are also separate savings plans you can buy to help you save up money specifically for medical costs.
An HRA, or health reimbursement arrangement, is a form of health expense account provided and owned by your employer. Because they own the HRA, your employer is the only one who can contribute to it. They can also determine if you can roll over unused cash to the next year. The money in it is used to pay for eligible expenses including medical, pharmaceutical, dental, and vision care, as defined by the employer.
A health savings account (HSA) is a bank account that you can use to pay for qualifying health care bills or to save for retirement. An HSA is available when combined with a qualified high-deductible health plan (HDHP), which has lower premiums/plan contributions and greater deductibles than a regular health plan. If you have an employer-sponsored health plan, the account is opened through the HSA provider chosen by your company. You, your employer, and others can contribute to your HSA up to a yearly limit determined by the IRS.
Flexible Spending Account (FSA)
An FSA is an employer-sponsored savings account that helps manage out-of-pocket healthcare bills. FSAs are tax-advantaged accounts, which means you can contribute to them before taxes and spend the money tax-free. FSAs allow account holders to save for eligible healthcare expenses by deducting pre-tax money directly from their paychecks. FSA funds can be used to cover deductibles, co-pays, and medical visits for you, your spouse, and any qualified dependents. Employers may contribute to their employees’ FSAs, but they are not obligated to do so.
Health Insurance Subsidies
Marketplace plans have two types of subsidy. The first type, known as the premium tax credit, lowers your monthly insurance costs. The cost sharing reduction (CSR) is a sort of financial aid that reduces your deductibles and other out-of-pocket payments when you visit the doctor or stay in the hospital. To get either sort of financial aid, you must enroll in a health insurance Marketplace plan.
Premium Tax Credit
A premium tax credit, sometimes known as a premium subsidy, is a tax credit that reduces or eliminates the amount of money that you would otherwise have to pay for getting individual or family health insurance. Unlike other tax credits, the premium tax credit can (and typically is) given upfront and all year. Each month, the IRS gives money to your health insurer, so you don’t have to pay as much yourself. Your tax return is then compared with the premium tax credit the following spring. You can also choose to pay full price for a health plan in your state’s exchange and then get the full premium tax credit on your tax return. Few people do this, however, because the cost of coverage without the advance premium tax credit is often out of reach for those who do qualify for the premium tax credit.
You must apply for coverage through the Marketplace and give information about your age, residence, household size, citizenship status, and expected income for the following year in order to receive the premium tax credit. Following the submission of the application, you will receive a decision indicating the amount of premium tax credit you qualify for. You can then choose to have the tax credit paid in advance, claim it later when filing your tax return, or a combination of the two.
Who’s Eligible?
To be eligible for the premium tax credit beginning in 2024, you must meet the following requirements:
Have a household income of at least the Federal Poverty Level (FPL), which is $14,580 in 2024.
Lack of affordable coverage through a workplace (including a family member’s employer)
Not be eligible for Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).
Have U.S. citizenship or proof of legal residency (Lawfully present immigrants with household incomes less than 100 percent FPL may also be eligible for tax subsidies through the Marketplace if all other eligibility standards are met).
If you’re married you must file your taxes jointly.
Cost Sharing Reduction
Cost sharing reductions are the second type of financial aid available. When you utilize covered health care services, cost sharing reductions reduce your out-of-pocket costs related to deductibles, copayments, and coinsurance. Cost sharing reductions are available to anyone who qualifies for a premium tax credit and has household incomes ranging from 100 to 250 percent of the poverty line. Cost sharing reductions (CSR) are only available through silver plans, as opposed to the premium tax credit, which can be applied to any metal level of coverage. CSRs are applied to a silver plan for qualified individuals, basically making deductibles and other cost sharing more comparable to that of a gold or platinum plan. Individuals earning between 100 and 250 percent of the FPL can use their premium tax credit to any metal level plan, but they can only receive cost sharing subsidies if they choose a silver-level plan.
Health Plan Tiers
When you buy health insurance through the federal or state Marketplace, the plans available are divided into four metal tiers: bronze, silver, gold, and platinum. The metal tiers allude to the portion of your medical treatment that each tier will cover, not the quality of care you will receive with one of these plans. Which plan tier you pick determines the amount of the bill you pay. The higher the coverage, the higher the cost, but the less you will have to pay out of pocket.
Bronze plans will cover 60% of costs; you will pay 40%
Silver plans will cover 70% of costs; you will pay 30%
Gold plans will cover 80% of costs; you will pay 20%
Platinum plans will cover 90% of costs; you will pay 10%
Why You Need Health Insurance
The most important advantage of having health insurance is having access to the care you need. Health insurance provides you with access to a vast network of doctors, specialists, hospitals, and laboratories. This network collaborates with you and with one another to assist you in focusing on prevention and wellness. In fact, the majority of healthcare plans provide free preventative services, such as immunizations and testing. To help you stay healthy and avoid illnesses and their consequences.
Furthermore, the Affordable Care Act requires Marketplace plans to cover pre-existing diseases. This means that even if you have a pre-existing condition, you can receive care without being rejected coverage or charged extra because of it. Because you’ll have regular access to the doctors and experts you need, your healthcare plan will also help you manage your care for any chronic illnesses you’re living with.
Your health insurance covers all of the greatest strategies to maintain your health. Having access to this type of continuous care can essentially lead to a longer and better quality of life. According to the National Library of Medicine, persons between the ages of 17 and 64 who did not have health insurance had a 40% higher mortality risk than those who did!
How EZ Can Help
Working with an agent saves you time and stress because you won’t have to decipher legal language or read fine text. Agents handle all of the legwork. So, you may rest assured that your coverage will best match your financial and medical requirements. Not to mention, EZ agents can save you hundreds of dollars on your health insurance premiums each year. We accomplish this by scouring the market for the most affordable plans, both on and off the market. In addition to locating and utilizing any available savings.
We don’t only assist you in finding a plan, we also assist you in keeping it up to date. When the time comes, we are also here to help you in filing claims with your insurance company and renewing your policy. To begin, enter your zip code in the box below. Alternatively, contact 877-670-3557 to speak with one of our licensed agents.
With over a decade of helpful content experience Cassandra has dedicated her career to making sure people have access to relevant, easy to understand, and valuable information. After realizing a huge knowledge gap Cassandra spent years researching and working with health insurance companies to create accessible guides and articles to walk anyone through every aspect of the insurance process.
