The Affordable Care Act (ACA) has made it easier for people without access to health insurance through their employers to purchase individual coverage. One of the main ways it has done this is the creation of the Health Insurance Marketplace. Where you can go to compare and shop for plans. These plans are much more standardized than plans were before the ACA, since they not only must now all cover the “10 essential health benefits,”. But they are also categorized into four “tiers” of coverage.
So, the first thing you should do if you’re in the market for individual health insurance is familiarize yourself with these tiers. Which are each named with a different metal type (Platinum, Gold, Silver, and Bronze). These different tiers do not indicate differences in quality of care. But in the percentages that you and your health insurance company will pay for your care.
In the sections that follow, we’ll break down the various health insurance metal tiers, as well as explain how to find out if you’re eligible for cost-sharing subsidies to help you choose the best plan for you and your family.
Health Insurance Plan Expenses
Before we get into the individual tiers, let’s take a look at the different expenses associated with all plans. There are five primary expenses you should be aware of, and they change from plan to plan. Make sure that you have accounted for these expenses in your plan’s budget.
In order to maintain insurance coverage, you’ll have to pay a monthly premium (or yearly premium if you prefer to pay in a lump sum). Premiums for plans will vary widely, but generally speaking, Bronze plans have the lowest premiums, followed by Silver plans, Gold plans, and Platinum plans.
Copays
A copay is a fixed amount that you will pay at the time of service for a medical service, or to see a doctor or specialist.
Deductible
Your policy’s deductible is the amount you’ll be responsible for paying before your insurance company begins covering any of your expenses. If your policy has a $1,500 deductible, for example, you will be responsible for paying that amount on covered care before your insurer begins paying for anything.
Bronze plans typically have the highest deductibles, meaning you’ll have to pay more out-of-pocket before your insurance kicks in. A Bronze plan’s deductible may be nearly twice as high as that of a Silver plan. Platinum plans typically have the lowest deductibles.
Coinsurance
Even after you’ve met your insurance plan’s deductible, you will most likely still have to pay a portion of your medical bills out-of-pocket, known as your coinsurance. A common coinsurance percentage is 20%, which means that once your deductible has been met (or until your out-of-pocket maximum has been reached), your insurance will cover 80% of your medical expenses, and you will pay the remainder. You can expect to pay the highest coinsurance for a Bronze plan.
The cost-sharing structure of the metal tiers is often misunderstood as coinsurance. Coinsurance is not the percentage that your Bronze plan covers (on average, 60% of consumer costs). All of your out-of-pocket costs (copays, deductible, and coinsurance) are included in the cost-sharing percentage of a metal tier.
Out-of-Pocket Maximum
While this isn’t technically an expense, it’s important to note that ACA-plans have what’s known as an out-of-pocket maximum. This means that once you pay a predetermined amount in healthcare expenses out-of-pocket, your insurance will begin to pay 100% of covered expenses. In 2023, the maximum out-of-pocket expense for an individual plan is $9,100, while the maximum for a family plan is $18,200.
The “Metal Tiers”
All plans sold on the Health Insurance Marketplace are placed into one of four coverage tiers established by the Affordable Care Act. You’ll most likely see these four categories referred to as “metal tiers” or “health coverage tiers.”
Don’t worry though, as we pointed out above, these metal tiers do not indicate differences in the quality of care you receive with these plans. These tiers only indicate how much of your healthcare costs you and your insurance company will be responsible for.
Plans were required by the ACA to begin classifying themselves in four actuarially determined categories: 60%, 70%, 80%, and 90%. This was done as part of the design process for the metal tiers and is meant to help you compare plans. Since these percentages indicate how much of your medical costs your insurance company will pay. Large group plans, such as those provided by an employer, are exempt from the tier requirements. But must have an actuarial value of at least 60%.
Remember, the cost of your plan always includes a number of factors. Like your monthly premiums, your annual deductible, copayments, and coinsurance. The metal tier you choose will dictate how much you pay for each of these. So let’s take a closer look at what this means for each metal tier.
Bronze
Bronze plans have the lowest monthly premiums of any plan type, but that doesn’t mean they are the cheapest plans. You will be responsible for a lot more of your care out-of-pocket if you have a Bronze plan. With these plans, your insurance company will cover 60% of your medical expenses. So, you will be responsible for the remaining 40%. Additionally, annual deductibles (the amount you are responsible for paying before your insurance plan kicks in to cover medical expenses) for these plans can be in the thousands.
So who are these plans aimed at? If you don’t anticipate frequent use of medical services, but still want to be covered in case of something like a serious illness or injury, a Bronze plan may be a good fit for your budget. But the high deductibles and coinsurance of these plans mean that you’ll have to pay a hefty chunk of your bill for even minor medical care out-of-pocket.
Silver
Silver plans are the most moderately priced plans. With these plans, your premiums will be a bit higher than those of Bronze plans. But you will pay 30% of the total cost of your medical care out-of-pocket, and your insurance company will cover the remaining 70%. In addition, the deductibles for Silver plans are lower than they are for Bronze plans.
So, if you’re willing to pay a little more for your premiums than you would with a Bronze plan, but want more of your routine medical expenses covered. Silver plans are a great choice because of their lower deductibles.
Gold
Gold plans have higher premiums than either Bronze or Silver plans do. But you will pay less out-of-pocket for medical services. If you have a Gold plan, your insurance company will pay for up to 80% of your medical expenses. Meaning you will only have to pay for the remaining 20%.
This is the best plan for you if you know you’ll be needing a lot of medical attention. Because it provides more comprehensive coverage, as well as lower deductibles. The higher monthly premiums will balance out, once you add up what you would have to pay for out-of-pocket with a lower tier plan.
Platinum
Platinum plans have the highest monthly premiums of any tier, but in exchange, they have the lowest deductibles and coinsurance. Your insurer will cover a whopping 90% of your medical bills with a Platinum plan. And you will only have to pay the remaining 10% out-of-pocket.
Just like with Gold plans, Platinum plans are a good option if you know you’ll be needing extensive medical care.
How Cost-Sharing Works
The term “cost sharing” is used to describe the splitting of healthcare expenses between you and your health insurance company. In fact, the name says it all. You share your medical costs with your insurer, like in the 30/70 split of a Silver plan. This means that you aren’t stuck paying for all of your medical bills on your own. But your insurer also expects that you cover a sometimes-significant portion of your care.
But, while the metal tier you choose will determine your cost-sharing percentage, your annual health care costs will be determined by the specific services you use and the specifics of your individual plan. For example, if you have a Bronze plan and you avoid all medical care for an entire year, only going in for an annual checkup. You will be responsible for less than 60% of your medical expenses for that year. However, if you get seriously ill and need surgery. You may end up paying for more than 60% of your care out-of-pocket.
How To Enroll
You can only enroll in an ACA metal tier plan during the period known as “Open Enrollment,”. Which begins on November 1 and ends on January 15 (in most states). During this time, you can also make changes to an existing plan. When you purchase a plan during the Open Enrollment Period, or OEP, your plan will go into effect on January 1 of the following calendar year.
Outside of the OEP, the only way to purchase or switch health plans is if you qualify for a Special Enrollment Period (SEP). You will need to experience a qualifying life event (QLE) in order to be eligible for one of these SEPs. QLEs include most significant transitions in your life, such as getting married, having a child, or changing careers.
EZ Can Help
Working with an EZ agent could mean saving hundreds of dollars on your premiums. Since we can search for plans both on and off the market for the best possible rates. Not only that, but we will also find any rebates for which you are eligible. And we won’t just help you find the best plan for you. We’ll also be here to support you after you make your purchase. For example, we’ll assist you in communicating with your insurance company regarding claims and policy renewals. To get started, simply enter your zip code in the box below. Or call one of our licensed agents at 877-670-3557.
There are a lot of moving parts involved in health insurance. As well as a lot of terminology to learn in order to understand your plan and its costs. Two of the most important terms to understand are premiums and deductibles. These are the two out-of-pocket expenses associated with your health insurance plan that will end up costing you the most money. Understanding these two terms, the difference between them, and how each operates will help you to better choose the best plan for your budget. Below we’ll explain how these two health insurance costs are interdependent and have an impact on each other.
Premiums
Like a Netflix or Spotify subscription, premiums are a monthly payment you make to maintain a service. In this case your health insurance plan. If you purchase an individual plan on the Health Insurance Marketplace, you will pay your premiums in their entirety. But you might be eligible for subsidies or tax rebates. If your employer offers a group health plan, the cost of your health insurance premiums may be partially or entirely covered by your employer.
How much you pay in premiums will vary based on several factors. Such as the policy you choose, the number of people in your family, and the insurance company you go through. In addition, when determining your premium, insurance companies may take into account factors such as your age, where you live, and whether or not you smoke cigarettes. For instance, because healthcare costs are assumed to increase with age, premiums for older adults are higher.
Premiums for individual health plans and family health plans function in the same way. There is only one payment required each month, so the cost itself is the only difference. The cost of your premium will be higher the more people who are covered by it. But, if you do the math, you might find that you’re paying less per person for a family plan than you would if you all had your own separate plans.
The only time this might not be the case is when someone in your family has significant health issues and another person rarely sees the doctor. In this case, it might be better to find plans that have lower premiums and higher deductibles for the healthier family member. And a plan with higher premiums and a lower deductible for the family member who needs more medical care. Let’s see why by taking a closer look at how deductibles work.
Deductibles
In most cases, your insurance plan will have an annual deductible. Which you will have to meet before your health insurance begins paying for any of your medical care costs. “Meeting” your deductible means that you will have to pay that amount in covered expenses to get coverage for anything other than preventive care. So, if your plan has a $2,000 deductible, for example, you’ll have to pay $2,000 out-of-pocket for things like lab work, minor surgeries, tests done at your doctor’s office, etc., and then your insurance plan will begin covering those things.
There are a variety of ways deductibles can work, and which medical expenses will count towards meeting them. Health insurance policies for individuals and families may include a deductible structure. In which the insurance company is not obligated to pay for services until the deductible has been met. But in some cases, a plan may cover some medical expenses before the deductible is met while excluding others. In addition, certain expenses like copayments won’t count towards your deductible.
Individual vs. Family Deductibles
Health insurance deductibles can either be applied per person or per family. The way individual deductibles work is fairly straightforward, while family deductibles can be a bit more complicated.
Individual – First, the easy part. If you have an individual health insurance policy, the money you spend on qualified medical expenses will count toward meeting your deductible. Once your plan’s deductible is met, you and your insurance company will begin dividing the remaining costs. Meaning you will pay what’s known as “coinsurance,” or a certain percentage of each bill. You’ll do this until you reach your policy’s out-of-pocket maximum.
Family – This is where things can get confusing, because your plan might have both an individual deductible and a family deductible. There are two main categories of family deductibles: embedded and aggregate. An aggregate deductible works the same as an individual deductible. Your plan will have one deductible, and everyone on the policy will be paying towards it.
Embedded deductibles, though, is where the confusion sometimes comes in. With an embedded deductible plan, there is both a family deductible and an individual deductible. So, each member of the family has a separate deductible in addition to the family’s deductible. Once a family member’s deductible is met, the insurance policy begins covering 100% of that person’s healthcare costs. Everyone else in the family will still have to meet their own deductible after that member’s deductible is met.
In addition, there is also a family deductible with these plans. And all family members will begin to have their expenses covered once the family deductible is met. Everyone will have to only pay their coinsurance until the out-of-pocket maximum is reached, once the family deductible is met.
Costs
The cost of your premiums and the amount of your deductible will depend on a variety of factors. It is difficult to give an accurate estimate of what you’ll pay without knowing your unique circumstances. Wut we can say that the average monthly premium price in the country is $456 per month.
Check out our state-by-state health insurance guides to learn more about how the health insurance market is regulated in your state. And to get a baseline estimate of the costs. You can also learn more about the health insurance plans that are available in your state. As well as ways to reduce the cost of your coverage.
As for deductibles, the average nationwide deductible amount depends on the metal tier you choose for your plan: Bronze, Silver, Gold, or Platinum. Keep in mind, lower deductibles mean a higher premium.
The average annual deductible amount for each tier is as follows:
Bronze – $7,482
Silver – $4,890
Gold – $1,650
Platinum – $745
How Premiums and Deductibles Work Together
Insurance premiums and deductibles are interrelated costs. Your plan’s premiums will be higher if the deductible is lower, for example. So, generally, your plan will either have a higher monthly premium with a lower deductible, or a lower premium with a higher deductible.
If you’re wondering which type of plan would be better for you. Consider that a higher premium with a lower deductible would be more appropriate for someone who has a pre-existing condition and needs to see the doctor frequently. And if you don’t often see the doctor or generally spend a lot on medical services, having a higher deductible won’t be as much of an issue for you. And you might be better off spending less on your premiums.
FAQs
How can I lower my premiums?
If you have individual coverage, and your household’s annual income is less than or equal to 400% of the federal poverty level, you might be eligible for subsidies or tax rebates. Which can lower the price of your premiums. If you have group health insurance through your employer, they might offer you reduced health insurance premiums or other incentives if you are able to meet certain health and wellness criteria.
What will increase my premiums?
Your health insurance premiums may increase for a variety of reasons. Including but not limited to inflation, adding family members to your plan, and relocating to an area with a higher cost of living. It’s also possible that your monthly health insurance premiums will go up if you opt for a plan with more generous benefits. Consider the policy’s premium in light of its benefits before making your decision.
Are premiums tax deductible?
If you have a plan through either the federal or state Health Insurance Marketplace, your premiums are tax deductible. If you’re self-employed, health insurance premiums are tax deductible. And you may also be able to deduct the premiums you pay for long-term care insurance. Before submitting a tax deduction claim, you may want to consult a tax expert.
Is a high or low deductible plan better for me?
If you do not anticipate having many medical expenses during the next plan year, selecting a health insurance policy that has a high deductible could give you the best value. When you anticipate having a lot of medical expenses in the near future, such as if you plan on having a baby, selecting a plan with a low deductible could help you get the most value out of your coverage.
What does “no-charge” deductible mean?
If you have a plan with a “no-charge” deductible, your plan will pay 100% of eligible medical expenses after you meet your deductible for the year. No-charge deductibles tend to be higher. But if you plan on using a lot of medical services for the year, it might balance out when you are no longer required to pay anything out-of-pocket.
How EZ Can Help
EZ.Insure provides access to local, highly trained insurance agents. Who will shop around for the best policy at the most affordable price. We can save you hundreds of dollars a year by searching both on and off the Marketplace for a plan that fits your needs. We can also find out if you’re eligible for any local discounts. And then apply them to your plan for you. And the best part is that we do all of this for free! To find out how much you could be saving, simply enter your zip code on the box below for free, instant quotes. Or call us at 877-670-3557 to speak to an agent who can answer all of your questions and find you the perfect plan.
Finding one insurance plan that’s right for you can seem like a big task. But in some cases, you might actually be wondering if it’s possible to have two health insurance plans. And the answer is yes: it is possible and legal to have two policies, a primary and secondary health insurance policy. And while it might seem like a lot of extra work to research and maintain two plans, having two different health insurance plans can actually help you save money on the overall cost of your medical care and treatment.
With that being said, having two plans can also mean paying twice as much each month for your premiums. As well as twice as much for your deductible. So if you are considering purchasing additional coverage, you’ll need to give serious thought to whether or not enrolling in a second health insurance plan would be the best option for you.
To help you make this decision, we’ve broken down how primary and secondary insurance policies work. So you can understand the difference and get a better idea of how two policies could work for you. And, as always, if you have any questions, or need help looking for the right policy – or policies – for you, contact an EZ agent!
Primary Insurance
Your primary plan will be the plan that will first cover any necessary medical care. This plan will pay before your secondary insurance plan kicks in. For instance, if you need to see a doctor or buy prescription drugs, your primary insurer will cover the costs of these services up to the coverage limits that it provides. Remember, though, as with any health insurance plan, you may still be responsible for cost-sharing, like coinsurance.
Secondary Insurance
In most cases, if you have a secondary insurance plan, it won’t begin to pay out benefits until after your primary insurance plan has exhausted its available coverage. After your primary insurer has paid its share of your medical costs, your secondary plan will begin to take effect to cover any additional costs that remain.
How to Get Two Plans
Getting secondary health insurance is similar to getting primary health insurance, but there are some differences to keep in mind. Here are the steps to getting a second policy:
Assess your primary policy – Review the policy documents for your current plan to find out what services are covered, how cost-sharing works, and what coverage limits there are. Think about your current and future health needs to find any gaps in your coverage.
Research secondary options – Options for secondary coverage range from plans that cover just one type of health service to plans that cover everything. Find out what kinds of plans are available to you and choose the one that fills in the gaps in your current coverage the best.
Understanding coordination of benefits – People can’t choose which of their two health plans is the “secondary” one. Before you sign up for another plan, make sure it will pay after the one you already have.
Apply and purchase – To sign up, follow the instructions for the plan you’ve chosen. Fill out the forms carefully and be ready to answer questions about your current health insurance. Pay your first month’s premium after getting approved for coverage.
How Does Having Two Plans Work?
When you have a medical bill, the first insurance that pays out is your primary insurance. It will pay up to its coverage limits. Then your secondary insurance will kick in and can pay part or all of the remaining costs. Please be aware that there are limits to the coverage provided by both the primary and secondary insurance. If the secondary insurer does not pay in full, the remaining balance will be your responsibility. Therefore, it is possible that you will have some remaining out-of-pocket medical costs. Even if you carry multiple health insurance policies.
There is a good chance that a Coordination of Benefits clause is included in your health insurance policy. This clause will lay out the predetermined order of how your plans will pay for your covered services. So, in the event that you or your medical provider file a claim for your care, the Coordination of Benefits document will specify which plan is accountable for making payments.
Examples of Primary and Secondary Plans
So, if you have more than one insurance policy, which policy is considered primary and which is considered secondary will be determined by your circumstances. The following are some examples of how primary and secondary plans work for different groups of people:
Married Couples – Say a wife has her own insurance but she is also covered under her husband’s group insurance from his job. The wife’s primary insurance would be her individual plan and her husband’s group coverage would be the secondary.
Minors under 26 – Under the Affordable Care Act, dependents can remain on their parents’ insurance until age 26. This means that an adult under this age could get their own health insurance policy from their employer while still being covered by the family policy. If that’s the case, the child’s health insurance would be the primary plan. And the parent’s would be the secondary plan.
Parents with separate plans – Say you are under 26 and still on your parent’s health plan. If they both have separate plans and you’re listed on both of them, you have dual coverage. The primary and secondary coverages are determined by a “birthday rule”. Meaning whichever parent’s birthday is earlier in the year will give you your primary insurance. And the one with the later birthday will give you your secondary plan. For example, if your mom’s birthday is in January and your dad’s birthday is in March. Your Mom’s insurance would be your primary coverage. This isn’t about which parent is older – the birth year doesn’t affect the order, only the birth month.
Medicare beneficiaries with group health plans – If you are 65 or older and on Medicare, but are still working and have insurance through your employer, Medicare will be your primary insurance if the company you work for has fewer than 20 employees. If your company has 20 or more employees, your group plan will be primary and Medicare will be secondary.
Out-Of-Pocket Costs
The cost of having two plans will generally be higher than the cost of having one plan. Since you will have to pay the premiums and deductibles for each of your health insurance policies. For example, consider this: you will not be able to use your secondary coverage to cover your primary’s deductible. You will also have to pay any copayments and coinsurance that are associated with each plan.
It’s also important to note that the rules of your primary plan will apply to both of your policies. So, for example, if your primary plan is a PPO plan. Your primary policy may stipulate that you can only use certain doctors and hospitals in your plan’s network. Your primary insurance won’t pay anything if you go to a doctor who isn’t in their network. The secondary insurance won’t either because you broke the primary plan’s rules by going to an out-of-network doctor.
In addition, if your provider charges you more than what your plan(s) considers to be reasonable, customary, or allowed under plan rules, you may have to pay the difference. A licensed insurance agent from EZ can help you understand the out-of-pocket costs associated with each of your plan options.
Weighing Your Options
There are positives and negatives associated with choosing to have a primary and secondary insurance plan. Just as there are with any other type of insurance. Let’s take a look at the pros and cons to help you decide if having two plans might be right for you.
Benefits
Extra Coverage – Having two plans could come in handy in the case of unanticipated medical expenses. And if you find that you frequently have to pay for your own medical expenses out-of-pocket, it may be beneficial to purchase a secondary health insurance policy.
No Gaps – Even if one of your health insurance policies lapses, you won’t experience a gap in coverage if you have a second plan. Your secondary health insurance will just become your primary automatically.
Complementary coverage – Having plans that are complementary, that cover different elements of your healthcare, will mean you’ll get more coverage and better benefits. You’ll be able to make up for what your primary health insurance doesn’t cover with your secondary plan.
Disadvantages
No guarantee – Even if you have two separate health insurance policies, your out-of-pocket costs may still not be covered in full. Keep in mind that the amount of your plans’ coverage cannot be more than the amount of your out-of-pocket expenses.
Extra expenses – Your two separate health insurance policies will still require you to make payments on the associated premiums and deductibles. This may result in additional expenses further down the road.
Overlapping – It’s possible that your coverage from two different health insurance plans will actually overlap if the plans are too similar to one another. Meaning you will not receive as many additional benefits as you might like.
FAQs
What is the birthday rule?
When children are covered by both parents’ health insurance policies, the birthday rule plays a significant role in determining which plan provides primary coverage and which provides secondary coverage. According to the birthday rule, whichever parent’s birthday falls earlier in the year will be the primary insurer. Secondary insurance is provided by the other parent’s plan. The year of birth of each parent does not come into play.
How do I know which is my primary insurance?
You don’t get to choose which plan will be your primary coverage and which will be your secondary coverage. Whenever you file a claim, your primary health plan will cover you as if you didn’t have a secondary plan. After that, your secondary health insurance will cover the rest of the bill. If you have two health plans, there are rules about how your benefits will work together. Some of these rules will be different for you based on your health insurance company and your situation.
Is having 2 plans worth it?
It depends. Having two health plans can save you money if one is free or both are inexpensive. Also, it’s best to make sure they work well together. Check to see if their coverages and benefits overlap or are too similar.
EZ Is Here to Help
Having both primary and secondary coverage can be complicated. It could work for you, but you’ll need to weigh the pros and cons carefully before deciding whether or not to invest in a secondary insurance policy. Feel free to ask EZ anything. Including if having two plans might be right for you, as well as for assistance in locating a secondary health insurance plan, if necessary. We will compare plan benefits and costs for you. And will assist you in locating affordable coverage that meets your needs. Simply enter your ZIP code below to get started with free, customized quotes right now! You can also give us a call at 877-670-3557 to have a qualified insurance professional discuss your needs and help you choose the best policy for you.
Diving into the world of health insurance can be intimidating. It’s easy to get overwhelmed when you’re looking for a plan because of all of the jargon and terminology that you need to become familiar with. But knowing what everything means as you research plans will help you to determine which one is best for you and your family, and will ensure you get the best coverage at the best price. Whether this is your first time buying health insurance or not, knowing the following health insurance terminology will help you make a more informed decision.
Actual charge is the dollar amount that is charged by a doctor for a particular medical service.
Actual Charge
This is the dollar amount that is charged by a doctor or other healthcare provider for a particular medical service or treatment.
Actuary
A person that is trained in the mathematical and statistical aspects of the insurance industry. They are the ones who calculate premium rates and assist in estimating the costs and savings of your health insurance plan.
Allowed Amount
Also sometimes called an eligible expense, a payment allowance, or negotiated rates, an allowed amount is the amount that your insurance company is willing to pay for a covered healthcare service. If your provider charges more than the allowed amount, you might have to pay the difference.
Balance Billing
This is a bill for the amount that you owe for a particular service after insurance has paid its share – in other words, the difference between the actual charge and the allowed amount. For example, if your provider charges you $200 for a service, and the allowed amount is $100, your provider will most likely bill you for the remaining $100.
Coinsurance
This is your share of the cost of a covered healthcare service, calculated as a percent of the allowed amount for the service. You generally have to pay the coinsurance plus any deductible that you owe. For example, if your health insurance plan’s allowed amount is $100 for an office visit and you’ve met your deductible, your coinsurance payment of 20% would be $20 for the visit.
This is a fixed amount you pay for covered health care services, such as visits to your doctor, specialists, or any other health care professional. Your co-pay will vary depending on the type of covered healthcare service you receive: visits to a primary care physician, specialist, and the emergency room will all be priced differently.
This is the amount you have to pay each year in medical expenses before your health insurance will kick in and begin to cover the rest of the year’s medical expenses. For example, if your deductible is $2,000, your plan will not pay anything until you have met your $2,000 deductible for covered healthcare services.
Drug Formulary
A list of prescription medications that are selected for coverage under a health insurance plan. Prescription drugs can be included on a drug formulary based on their efficacy, safety, and cost-effectiveness. Some plans will place medications on different tiers, which will change the price of the medications. Some health insurance plans may require that patients obtain preauthorization before non-formulary drugs are covered.
Durable Medical Equipment
If you need any medical equipment, such as crutches, oxygen apparatus, wheelchairs, or even blood testing strips for diabetes, your health insurance plan will most likely cover the cost of these things up to a certain point. Generally, you will have to pay coinsurance for any durable medical equipment that you receive.
This type of plan has lower monthly premiums, but a high annual deductible. These plans are generally aimed at people who are healthy and do not go to the doctor often, and so do not expect to have to meet the high deductible.
In-Network Vs Out-of-Network
Your plan will have a network of healthcare providers, if you see any doctors that are not in your network, you might have to pay out of pocket.
If a healthcare provider is in-network, that means your health insurance plan will cover services provided by them. These are very important terms to know, because if you seek services from a healthcare professional who is considered out-of-network by your plan, you might have to pay for the service completely out-of-pocket.
This is the most that you will have to pay for medical services during a policy period, which is usually a calendar year. Your premiums and most other medical expenses paid out-of-pocket will count towards your limit, but you should be aware that some plans will not count co-payments, deductibles, or coinsurance, so it’s important to check your policy.
Premium
The amount that you will pay for health insurance every month. Your premium does not include any other expenses. If you do not pay your premium, you will lose your health insurance coverage.
Specialist
A healthcare professional that specializes in a certain condition or area of the body. Specialists include gastrologists, dermatologists, and podiatrists, for example. Seeing a specialist will cost more than seeing your primary care physician, so your co-pays and actual charges will be higher.
UCR (Usual, Customary, and Reasonable)
This is the amount charged for a medical service within a specific geographic area, based on what providers in the area usually charge for the same or similar medical service.
The best way to understand how health insurance works, and to find the right plan for you and your family’s specific needs, is by working with an agent who specializes in health insurance. EZ can help: we offer a wide range of health insurance plans from top-rated insurance companies in every state. And because we work with so many companies and can offer all of the plans available in your area, we can find you a plan that saves you a lot of money – even hundreds of dollars – even if you don’t qualify for a subsidy. There is no obligation, or hassle, just free quotes on all available plans in your area. To get free instant quotes, simply enter your zip code in the bar above, or to speak to a local agent, call 888-350-1890.
The Open Enrollment Period is coming to an end soon, and if you still haven’t looked into your health insurance options for the new year, now is the time to do so. But we get that picking a plan can be overwhelming because of all the options out there, so we want to give you the inside scoop on finding the best plan for you: your best bet is to work with an insurance agent. They know the ins and outs of health insurance and work with every insurance company, so they can get you the best possible plan. The best part? If you work with an EZ agent, we will compare plans for you for free! So if you’re ready to get started, we’ve got the most important questions to ask when requesting health insurance quotes from your EZ agent.
What Types Of Plans Are Available?
There are a lot of plans – and we mean A LOT – of different plans out there to choose from. There are metal tier plans, HMOs, PPOs, POSs, EPOs, and more. Each plan offers different levels of flexibility, coverage options, and rates; your available options also depend on where you live, so be sure to ask your EZ agent which plans are available in your region. We will gladly go over every single option and discuss the difference between each plan, so we can help you determine which one is right for you and your family.
Health plans available on the ACA Exchange are separated into four metal tiers. These tiers do not indicate the level of care you will receive; rather, the tiers let you know how much you will pay for care and how much your insurer will pay. The tiers are:
Bronze– Lower monthly premiums, but a higher deductible and copays. You will usually pay an average of 40% of costs of care, and your insurer will pay 60%.
Silver– Moderate monthly premiums and moderate medical costs. You will pay 30%, and your insurer will pay 70%.
Gold– Higher monthly premiums with lower out-of-pocket costs. You will pay 20% and your insurer will pay 80%.
Platinum– Highest monthly premiums and lowest out-of-pocket costs. You will pay 10% and your insurer will pay 90%.
We will be able to go over this in more detail, including what each type of plan will cover and how much you will pay, so you can have a better understanding of how these plans work.
Can I Add Supplemental Insurance?
Dental and vision are considered supplemental insurance plans; some health insurance plans do not offer these, so you will have to ask if they are part of the plan you are looking into. If they are not, we can help you find affordable dental and vision plans.
What is A HDHP & Will It Work For Me?
High deductible health plans are exactly what they sound like: these plans have high deductibles, but in exchange, you will have low affordable monthly premiums. These plans are generally for healthy people who only see the doctor for annual physical exams and do not have any chronic conditions that require constant medical attention, and who will most likely not have to pay their whole deductible. For 2022, the Internal Revenue Service has defined a HDHP as any plan with a deductible of at least $1,400 for an individual, or $2,800 for a family.
Medications are covered differently on plan’s drug formulary, which determines how much your medications cost.
Figuring out the cost of your prescriptions can be a little complicated since different insurance companies can charge differently for the same drug – some drugs might even be covered differently by the same insurer depending on the plan you choose. Basically, insurers put medications into a drug formulary, which is divided into four tiers:
Tier 1– Inexpensive generic drugs
Tier 2- Brand name drugs and more expensive generic drugs
Tier 3– Non-formulary drugs, generic or brand name
Tier 4- Specialty drugs
To find out which plans cover your medications and how much you will be charged based on their placement in the insurer’s drug formulary, you need to speak with an EZ agent. We will review each plan available in your area and their drug formularies to make sure that your medications are covered, and that they will not cost you an arm and a leg.
What About Out-of-Network Coverage?
Some plans, like HMOs, will not cover out-of-network coverage, but PPO and POS plans do cover out-of-network coverage in case of an emergency. If you travel or visit family in other parts of the country often, you’ll definitely want to consider a plan that covers out-of-network emergencies; otherwise, if you have an accident while away from home, you could be stuck with a bill that you have to pay out-of-pocket.
Do I Need Referrals?
With some plans, you’ll need a referral from your primary care physician (PCP) to see a specialist, like a gastroenterologist or an orthopedic doctor. If you want to skip this step and see a specialist whenever you feel necessary, we can help you find a plan that does not require a referral. You’ll have more flexibility with a plan that doesn’t require referrals, and you won’t have to pay a PCP copay just to get a referral to see a specialist.
There are so many things to think about when looking for a health insurance plan for you and your family. Do you want more flexibility? Supplemental insurance? Cheaper prescriptions? The easiest way to find the right plan for you and get the answers to these questions is to work with an EZ agent. We will compare plans, go over every option, discuss your needs, and help you sign up for the plan you need, all at no cost to you. Our services are completely free, with no hassle and no obligation. Speak to an EZ agent now, before the OEP ends! Get free health insurance quotes by entering your zip code in the bar above, or to speak with a local agent, call 888-350-1890.
The Open Enrollment Period is almost over: you only have until January 15 to purchase or change your plan! With that being said, though, some states have chosen to extend their deadline; they can do this because, under the Affordable Care Act (ACA), each state can run its own health insurance exchange, or Marketplace, in which people can shop for health insurance.
This state-based Marketplace is a government agency that is created and maintained by the state, and that offers subsidized ACA plans for residents of that state. You can buy a plan from your state’s Marketplace, or you have the option of buying off-exchange coverage from an insurance company; if you do this, you will not get premium subsidies and cost-sharing reductions– those are only available through the exchange. So which states run their own Marketplaces and what does that mean for you?
State-Run Vs. Federally Run Exchanges
When the ACA was passed in 2010, it provided funding and laid out rules for states to be able to establish their own exchanges; if states chose not to have their own exchange, the federal government would then step in and offer insurance for that state’s residents. So, many states chose to do it themselves so they could have more control of their Marketplace, and make it more profitable and sustainable. The federally run exchange, accessible through Healthcare.gov, is used in 36 states. The other 14 states (and Washington D.C.) have their own exchanges.
States With Their Own Exchanges:
California (Covered California)
Deadline is January 31
Colorado (Connect for Health Colorado)
Connecticut (Access Health CT)
District of Columbia (DC Health Link)
Idaho (Your Health Idaho)
Maryland (Maryland Health Connection)
Massachusetts (Massachusetts Health Connector)
Deadline is January 23
Minnesota (MNsure)
Nevada (Nevada Health Link)
New Jersey (Get Covered NJ)
Deadline is January 31
New York (New York State of Health)
Pennsylvania (Pennie)
Rhode Island (HealthSource RI)
Deadline is January 31
Vermont (Vermont Health Connect)
Washington (Washington Healthplanfinder)
If you live in a state that has its own exchange, your health insurance plan options and prices might be a little different than if you only have the option of using Healthcare.gov or going off-exchange. In addition, depending on where you live, your OEP might be extended! But just because your state is in control of the Marketplace, that doesn’t mean you can’t find a great affordable ACA-compliant health insurance plan that is right for you by working with an EZ agent.
Looking For Insurance?
The best way to get the right plan for you and your needs is by working with a licensed health insurance agent. At EZ, our agents are highly trained and work with the top-rated insurance companies in the nation, in every state! We will connect you with a local agent who will go over your medical needs and budget, and sift through all the available plans in minutes. We’ll quickly find you a plan that will save you money – especially now, with the premium subsidies President Biden has extended to all Americans. You could save hundreds of dollars a year! No hassle and no obligation. To get free instant quotes, simply enter your zip code in the bar above, or to speak to a local agent, call 888-350-1890.
