Now is the moment to select your healthcare plan for the upcoming year through the insurance marketplaces of the Affordable Care Act. Experts advise against solely considering cost when making your decision.
To avoid unexpected financial expenses, purchasers should have an understanding of a plan’s coverage, functioning, and potential upfront costs for medical treatment.
The annual enrollment period for individuals seeking to purchase coverage starting on January 1st will begin on Wednesday and continue through December. This opportunity is open to those who are not currently covered through their workplace, Medicare, or Medicaid.
The marketplaces saw record enrollment of more than 16 million for this year. Officials expect business to be brisk again for 2024 plans partially because people have been losing Medicaid coverage that they kept through the COVID-19 pandemic.
When evaluating marketplace plans, there are several factors to take into account.
The marketplaces provide a variety of premium options for coverage costs. These options are categorized as platinum, gold, silver, and bronze levels. The bronze level typically has lower costs, but also requires patients to contribute more towards their healthcare expenses.
Customers are eligible for tax credits based on their income to assist with purchasing coverage. However, it is advised by professionals to carefully consider the amount they report on their application.
The tax credits are calculated based on projected earnings for the upcoming year, rather than current income. This could result in individuals who underestimate their future income having to reimburse a portion of the assistance they received.
Jeremy Smith, who leads West Virginia’s health insurance navigator program, states that numerous individuals who are unfamiliar with the marketplace are unaware of the assistance available to them.
According to him, individuals are unaware until they have a reason to be informed.
Switching from Medicaid to a low-cost marketplace plan may result in deductibles that must be paid before most coverage begins, potentially amounting to thousands of dollars.
According to Smith, many individuals struggle to comprehend the concept of deductibles. They are accustomed to having health insurance that covers all expenses.
Some plans may have maximum limits of over $9,000 for individuals and $18,000 for families. This is the highest amount a person will have to pay in a year for services covered by insurance before the insurance covers all costs. It is important for shoppers to consider if they are able to handle large expenses like this.
The marketplace offers assistance for these expenses. Individuals with incomes below 250% of the federal poverty level are eligible for cost-sharing reductions if they choose a silver plan. This results in reduced deductibles and out-of-pocket limits.
Sabrina Corlette, co-director of Georgetown University’s Center on Health Insurance Reforms, stated that many individuals who have been enrolled in Medicaid will probably be eligible for these reductions in cost-sharing.
Insurance companies create networks of hospitals and physicians for coverage. Patients who have established doctors should check if they are included in the network of the plan they wish to buy.
Most marketplace health plans do not cover non-emergency care if it is received outside of their network. This is typically the case for Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs).
Cynthia Cox, a vice president at KFF, a nonprofit organization that researches health care matters, stated that individuals are typically limited to the doctors within their network.
Around 80% of the plans available on the exchange are EPOs or HMOs, as stated by a KFF study. This percentage may differ depending on the state.
Health Maintenance Organizations (HMOs) also mandate that patients have a designated primary care physician who oversees their medical treatment and advises on necessary visits to a specialist. Without this recommendation, the cost of the specialist visit may not be covered.
Health insurance providers have been attempting to restrict visits to the emergency room to only urgent and life-threatening situations. They may deny coverage for claims that do not align with this criteria.
According to Kelly Fristoe, a self-employed insurance agent in Wichita Falls, Texas, this may be a significant adjustment for individuals on Medicaid who frequently seek medical attention at emergency rooms.
Brokers assist individuals in navigating the various factors involved in selecting marketplace plans. Typically, they receive a fixed payment that is included in the overall coverage expenses.
Marketplaces run by the state also employ navigators, such as Smith, who can help individuals navigate and comprehend the available options. These navigators are funded by the government and provide their services at no cost to shoppers. However, they are not able to suggest specific choices.
Experts advise initiating your search well in advance of December to avoid a last-minute rush that often occurs when enrollment periods are coming to an end.
The Howard Hughes Medical Institute’s Science and Educational Media Group provides support to the Associated Press Health and Science Department. The AP is fully accountable for all of its content.