Where Should Families Start to Find Affordable Health Insurance?

Health Care

As most people in America now know, if you are 64 or younger, you are subject to the new Affordable Care Act. The marketplace can be difficult to navigate, and most folks who are not savvy about the ins and outs of these new health insurance plans or about the ACA itself may become frustrated by the plethora of information available that is not easily consolidated into an understandable format.

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Most folks who find themselves above the 138% federal poverty level (a 2014 annual household income guideline ranging from $16,105/yr. to $55,324/yr. in most states, depending on the size of the family) must either purchase a qualified, major medical health insurance policy for every member of your nuclear family or face a government imposed tax penalty. For most people, the 2015 penalty will be either 2% of your annual household income over the filing threshold ($10,000 for an individual or $20,000 for a married couple), with the maximum penalty being the national average premium for a bronze plan, OR $325 per adult and $162.50 per child under 18, the maximum penalty being $975, whichever is higher. If you earn under 400% of the federal poverty level

Steps to finding the best plan for you and your family:

While the whole process can be daunting and can seem somewhat unfriendly, there are a few things you can do to make the process easier.

1. Consider using a broker. Brokers are licensed insurance agents who have access to the health insurance marketplace, to subsidies and to multiple insurance companies. They can use their expertise to both educate you and to find the best plan and price point for you.

2. If you are reluctant to use a broker, try calling the federal health insurance marketplace at 800-318-2596. The representatives are navigators, and thus are not licensed agents. Navigators can tell you what plans are available in your area, and whether or not you qualify for a subsidy, but they can not make recommendations for you based on your individual needs.

3. If you're not interested in speaking to anyone, you can access multiple available plans for your area while also checking for your subsidy allowance by starting online at HealthCare.gov.

Keep a few things in mind when researching plans on your own:

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• There are five categories of qualified plans for the ACA: Catastrophic, Bronze, Silver, Gold and Platinum. All qualified plans provide the same essential health benefits, and all cover pre-existing conditions and offer free preventative services.

• Be prepared to decide between an HMO or PPO. HMO's will require you to see your primary physician (with the exception of routine well-woman visits to a gynecologist and obstetrical care) for a referral before visiting a specialist, and your network of providers is regional so you will not have as wide a selection of providers as those you might find in a PPO's network. By contrast, a PPO will give you more flexibility in that you will not be required to see your primary physician before seeing a specialist and you can stay inside or go outside of your network (with differences in copays and coverage).

• If you or a family member are taking multiple or expensive brand-name medications, make sure the plan you sign up with has prescription drug coverage with a low to zero deductible and a reasonable copay structure that limits your per-prescription liability to a dollar amount instead of a percentage of the total cost.

• Take into consideration your travel habits. If, when you travel, you like to be able to see a doctor or visit an urgent care in a non-emergent situation, make sure you understand the geographical restrictions to your network.

• If all you can afford is catastrophic coverage or a Bronze plan, in addition to your monthly premium, you will generally have to pay for all of your care (from doctors appointments and lab tests to ER visits and hospitalizations) until your deductible has been met. If you are healthy enough, you may also qualify for a “gap” insurance plan to bridge that gap between your deductible and your coverage. Gap plans are medically underwritten, so you do have to be reasonably healthy to purchase one, and you can't have any upcoming surgeries or tests scheduled for which you are seeking coverage. Once in place, the gap plan will pay a portion of your deductible on both an outpatient and inpatient basis, so that you don't have to pay for the whole doctor or lab visit yourself, and so that you don't have to produce a lump sum all at once in the event you need expensive testing, treatments, surgeries etc.

• If you are considering no insurance at all because it is just too expensive, research your health indemnity options. Health indemnity policies can cover things like doctor's appointments, lab tests, ER visits, surgeries, various treatment regimens and hospitalizations. These plans are typically less expensive than a qualified major medical plan, but at the same time, they are limited benefit policies and only cover a certain dollar amount for every visit to the doctor, lab, outpatient facility or hospital and the annual and lifetime benefits are also limited. You will also still pay the tax penalty for not having a “qualified” health insurance plan, but if you're considering taking nothing because of cost, you'll want to consider your indemnity options because some coverage is, most definitely, better than none at all.

Finding your way through the ACA's new health insurance maze is challenging for most, but by following these few steps, your search for the least expensive, most comprehensive coverage available may be just a bit easier. Happy hunting.

Lea Weaver is a licensed Insurance Broker/Team Lead at 1-800-Medigap
Caddo Mills, Texas

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