Health Insurance Marketplace Tips

Tips for Buying Coverage on the Health Insurance Exchange

For Americans who don’t study health insurance or haven’t ever bought their own insurance plan, the marketplace may seem confusing, especially with the introduction of tax credits.


“This is not explained very well, the average person will never get it,” a woman said as she took a Blue Cross handout on the first day of open enrollment.


Consumers may not understand the marketplace or health insurance, or feel it necessary to apply. But if the law benefits you as an uninsured, low-income or chronically ill person, it may be easier to grasp the knowledge.

Several accounts of sick Americans who have gone without coverage for years attest to the eagerness to sign up for a subsidized health plan.


An insurance counselor at Houston nonprofit Gateway to Care spoke with an uninsured woman who couldn’t wait for the exchange to open in Texas, saying, “Do you know you’re saving our lives? We’re gonna live!”


The woman and her husband both have chronic illnesses, diabetes and a heart condition, and skip days of medication as they cannot afford them all.


Despite glitches for the first few months of open enrollment, millions of people have successfully signed up for coverage in the state- and federally-run health insurance marketplaces. Affordable, guaranteed issue coverage is available, even if you’re not sure what exactly that means.




Finding the Right Plan

If you have experience shopping for health insurance, buying coverage on the exchange shouldn’t be too surprising with the exception of the tax credit eligibility step. All you have to do is use a subsidy calculator in order to find out if you qualify for premium or cost sharing assistance on the exchange. Fill in your age, income and how many people are in your household. Done.


You can estimate subsidies for yourself by finding your state, or call an agent for a clearer picture at 888 803 5917.


Choosing the right health plan to fit your needs depends on several factors. If you have health problems to address, you may invest in a higher premium to save on medical care. If you haven’t seen a doctor in a few years, the best plan may be the one with the lowest premium. Regardless of health status, every applicant should consider the provider network they are going to use, the costs and the quality of their plan.

Each exchange website also features a tool where you can compare and contrast health plans (like our quote engine) for cost, coverage and network size. Benefits and premiums can vary greatly from one plan to another, so make sure to look at each variable — not just the monthly rate — before you select a plan.


Providers: Is Your Doctor In-Network?

If you already have a primary care physician you like, check with them, or the health plan, to see if they are included in the plan. This also goes for other providers like nearby hospitals, your preferred OB-GYN or physical therapist.


Don’t count on your doctor of choice to be included unless you ask, especially because some health plans have created narrower networks in order to cut costs and offer lower premiums. To find out, the exchange website should list a provider directory where you can look up the information.


As many provider directories are outdated, however, the most accurate information can be obtained directly from your provider. Call the doctor or facility of your preference before you enroll to ask if they are part of the specific exchange plan network for the company you are considering — or any carrier’s network on the exchange.


Prescriptions: Coverage and Costs

It may be less convenient than the Medicare Part D (prescription drug plan) site, where you can search for medications and find out who covers them, but if you need to check that your prescriptions are covered under an exchange plan, you’ll have to follow a few links.


If you’re not the researching type, ask an insurance agent who can look up the information for you.


Official marketplace sites should include links to each health plan’s website, where you can then look up the formulary and find out what drugs are covered. It’s not always the easiest information to find, however.


Federal law requires all insurers to provide plan transparency via a summary of benefits and coverage document for each plan.


In the benefits summary, you can find information about the plan’s deductible, covered services, and copays for generic, name brand and non-formulary or specialty drugs. The schedule of benefits is always included when you’re shopping for coverage through our site, and the government thought it might be smart to make this document mandatory for exchanges.


Consider Total Expenses, Not Just Premiums

It is always encouraged to purchase a plan that you can afford, which includes not only a monthly payment that fits your budget, but your total potential financial exposure: deductible, coinsurance or copays, and annual out-of-pocket maximums, as well. Factor in the amount of care you anticipate using in order to estimate the costs you will endure.


While health plans on the exchange cover a broad selection of benefits, if you choose a plan with high cost sharing, you’ll be responsible for 30 or 40 percent of medical bills when a copayment isn’t an option.


If you’d rather pay a smaller premium and don’t mind paying more for care, especially if you seldom obtain it, a bronze or silver plan may be appropriate. Perhaps even a catastrophic plan would be apropos if you’re under age 30 and want to evade the individual mandate tax penalty.


If you do expect to use your health insurance throughout the year due to health problems or age, a better balance of costs may be found in a gold or platinum plan, as their higher premiums will give you access to lower cost sharing.


As with any health plan, check that the benefits will benefit you, with coverage that meets your needs. Also, look for limits on services. Just because the health care law increased access to care doesn’t mean the exchange isn’t still an insurance plan. There are limits on coverage and some services that will not be covered depending on the company and state.


Enroll Early

Each year, open enrollment lasts from October to March, and it’s optimum to start early. Not waiting until the last minute to enroll will help you choose the best plan to fit your needs, and answer any questions you may have.


If you want your coverage to begin on the first of January so that your plan year follows the calendar year, you must enroll by December 15.


Giving ample time to determine your tax credit eligibility, the coverage and network you prefer, and the costs you will accrue is essential.

Leaving these decisions to the day before open enrollment ends may result in disappointing coverage that you haven’t researched thoroughly, and a slow enrollment process.


Beware of Exchange Impostors

Yes, the exchanges are confusing, and some people are taking advantage of the uninformed with lookalike Obamacare insurance sites. Although licensed agents and those with access to federally-approved resources are able to help people enroll in marketplace plans, there are scam artists — as the government warned us — playing off the idea of the exchange.


Fake websites and callers posing as health insurance agents or navigators working for the exchange may be able to steal your identity by obtaining the personal and financial information submitted while enrolling for health insurance.


In certain instances, you could just be directed to a site that doesn’t sell exchange coverage at all but will sign you up for private health insurance after advertising Obamacare plans. Other times, you could be at the effect of a site or individual intending to steal your identity.


To avoid this, research who you’re shopping with. For example, our licensed agents are certified to sell exchange plans in many states.


Our agents have completed training to help you get coverage from your state’s marketplace. We can help you enroll and find a great plan at no cost. Security is a high priority for us, so you can be sure your information is only seen by your insurers and your agent.

View our Privacy Policy for more details on how we keep our customers safe.


If you want to be entirely sure you’re shopping in the right place, call us for professional assistance, or visit (or your state-run exchange’s website) directly.


For a comprehensive list of exchange information, find your state.


Tax Credits: Calculate Earnings Cautiously

A study by Avalere Health estimated that about 80 percent of those who qualify for exchange plans are also eligible for subsidized coverage. Tax credits are issued to individuals and families with income up to 400 percent of the poverty line, based on projected income for the following year. This is why the IRS is now involved in health insurance.


Especially for those who ride the line of 400 percent FPL, a slight increase in pay or unexpected bonus could put you over the limit for tax credit eligibility and coverage could cost you more. As long as you calculate as closely as possible and provide updates when you receive greater pay, you will be able to avoid an additional tax.


If you let the exchange know as soon as your income changes, they can adjust your tax credit immediately and all will be well. Hopefully, you still qualify. If not, you can choose to enroll in a plan on or off the exchange for about the same price, but the network selection will be better on the private market.