Things to Think About When Picking a Health Plan on Your State’s Marketplace

American College of Obstetricians and Gynecologists (ACOG)January 13, 2015Articles

All health plans offered in the state marketplace cover the same essential health benefits. These include doctor’s visits, hospital stays, medicine, pregnancy care, and more.

State MarketplaceMarketplace plans can offer additional benefits, like vision, dental, or care for a specific disease or condition. There can be small differences in how and whether plans cover these other benefits. As you shop for a plan on your state’s marketplace, you’ll see what benefits each plan covers. This information will be helpful if you have specific health care needs.

There are 4 types of plans offered on the state marketplaces.

Each type offers the same essential health benefits. They differ based on other services they cover and how much you’ll pay for premiums and out-of-pocket costs.

  1. Bronze
  2. Silver
  3. Gold
  4. Platinum

The type of plan you pick affects how much your premium costs each month and what portion of the bill you pay for things like hospital visits or medicine. It also affects your total out-of-pocket costs – the total amount you’ll spend for the year if you need a lot of care.

What are out-of-pocket costs?

A Premium is what you must pay every month to stay enrolled in your health insurance plan, whether you use care that month or not. Think of it as a membership fee. It is separate from what you pay only when you use health care. If you don’t pay your premium every month, you could lose your insurance coverage.

A Deductible is the amount you must pay for your health care before your health plan will pay anything. Your doctor or hospital will send you a bill after you have received your care.

For example, if your deductible is $1,000, you will have to pay $1,000 out-of-pocket before your plan will begin to pay for any of your care. The higher your deductible, the more you have to pay on your own before your insurance will cover any costs.

A Copayment or copay is an amount you may be required to pay for a doctor’s visit, hospital stay, or medicine. A copay is usually a set dollar amount, due at the time of service.

For example, you might pay $10, $20, or $30 for a doctor’s visit, hospital stay, or medicine. Your health plan pays the rest. Copayments are often between $0 and $50 depending on your insurance plan and the type of visit or service.

Co-insurance is your share of the costs of a covered health care service, often a percent of the total cost for the service. Your doctor or hospital will send you a bill after the insurance company has decided how much it will pay for the care your received.

For example, if your health plan pays $90 for a doctor’s visit, you 20% co-insurance payment would be $18. Your health plan then pays the rest: $72.

Your out-of-pocket limit is the most you will have to pay during a policy period, usually one year. Your health plan pays 100% of the costs for essential health benefits once you reach your limit. You still have to pay your premiums. You may also still owe copays or co-insurance for other benefits or out-of-network care. The maximum out-of-pocket limit for any plan for 2015 is $6,600 for an individual plan and $13,200 for a family plan. Plans can have separate out-of-pocket maximums for drug coverage and medical benefits.

You may qualify for help paying for your plan and out-of-pocket costs.

You may be able to get lower costs on your premiums and out-of-pocket costs when you use or your state marketplace. You’ll find out how much you can save when you apply.

You should balance your monthly premiums and out-of-pocket costs.

Everyone with private health insurance has to pay monthly premiums. It’s also important to know how much you’ll have to pay out-of-pocket for services when you get care.

Your medical spending = Your monthly premium + Your out-of-pocket costs (deductibles, copays, co-insurance)

So it’s important to look at BOTH premiums and out-of-pocket costs when buying a plan. Keep this in mind: The lower the premium, the higher the out-of-pocket costs. The higher the premium, the lower the out-of-pocket costs.

  • With a Bronze plan, you’ll pay a lower premium, but pay higher costs when you go to the doctor or get other care.
  • A Silver plan can be a good balance between monthly premiums and out-of-pocket costs.
  • If you have a Gold plan, you’ll pay a higher premium, but lower costs when you get care.
  • Platinum plans have the highest monthly premiums and lowest out-of-pocket costs.

Remember, you must pay your monthly premium and medical bills. Some providers will not see you if you have unpaid medical bills. Contact your doctor’s office if you can’t afford to pay your medical bills. They may be able to help you set up a payment plan.

Source: American Congress of Obstetricians and Gynecologists

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