Consider Services and Costs.

Per the Affordable Care Act, all plans must cover the basic 10 essential healthcare services (see minimum requirements for health plans below).  However, in addition to these services,  carriers may offer additional coverage.  The cost of additional coverage will vary depending on level of services covered and who the carrier is.  The Affordable Care Act has also mandated that consumers have a choice between four levels of coverage.  Accordingly, Platinum covers 90% of your healthcare costs, Gold which covers 80% of your healthcare costs, Silver covers 70% of your healthcare costs and Bronze covers 60% of your healthcare costs.

Accordingly, as you compare monthly premiums, you should also compare copayments, deductibles, and coinsurance.

Copayments – the fixed dollar amount you must pay for a doctor visit or other covered service.  Accordingly, for those individuals who visit the doctor frequently, a plan with a low co-pay may be a good choice.

Deductibles – a deductible is the amount you must pay annually before certain healthcare services will be covered.  Accordingly, a high deductible, low premium plan is often a good choice for those individuals who are generally healthy.

Coinsurance – after your deductible is met, you will still pay for a portion of your medical services, referred to as coinsurance.  For example, many policies pay between 60% to 80% of your healthcare costs, while you cover the remaining 20% to 40%.

You have an annual out-of-pocket maximum that includes copayments, deductibles and coinsurance.  Once you reach your out-of-pocket maximum, the insurance company pays 100% of your healthcare costs.

Consider the plan’s healthcare provider network.  Whether an HMO or PPO, all health plans have an approved provider network.  If you use healthcare service providers outside of the network, there is a good chance those charges won’t be covered by your policy.

Although short-term health plans are not ACA compliant, they can cover you immediately for a limited period of time. Designed for times of transition, they bridge gaps in coverage for individuals and families.  Short term plans are generally less expensive than traditional health insurance, but they do not provide full coverage and they typically do not cover pre-existing conditions. Based on your needs, you can select the length of time, which varies by state (1 to 11 months in some states, other states allow renewing up to 3 years) and from a range of available deductible amounts.

As of January 1, 2014, insurers are prohibited from discriminating against individuals with pre-existing conditions.

Your health plan will have a “grandfathered” status if the it was purchased before March 23, 2010. “Grandfathered” plans do not have to follow the rules and regulations of the new health care reform law. “Grandfathered” plans also do not have to offer the same benefits, rights and protections of plans under the new health care reform law which means that on many old plans, individuals can still face situations such as be dropping from coverage for reasons other than fraud, being denied treatment for preexisting conditions and facing annual and lifetime dollar limits.

Yes. With the health care reform law, individuals have the right to appeal a health insurance company’s claim denial. The first step in appealing a claim denial is to make an “internal appeal” through your health insurance company. An “internal appeal” is a formal request for your health insurance company to perform a full review of its original decision. Should your health insurance company maintain its claim denial even after the “internal appeal,” the health care reform law allows you to initiate an “external review,” in which you can have an independent third party either confirm or overturn your insurers’ decision.

No.  Under the Affordable Care Act, individuals were originally required to buy health insurance or be subject to a tax “penalty.” However, the Individual Mandate was repealed by the Trump Administration and has not been reinstated to date.

All private health insurance plans are required to offer “essential health benefits,” which are services that all plans must cover (in all categories of plans –bronze, gold, and platinum). These essential health benefits include the following items and services:

  • Emergency services
  • Ambulatory patient services
  • Mental health and substance use disorder services (including counseling and psychotherapy)
  • Laboratory services
  • Hospitalization
  • Pregnancy, maternity, and newborn care
  • Prescription drugs
  • Rehabilitative and habilitative services
  • Pediatric services
  • Preventative and wellness services and chronic disease management

While all plans must cover essential health benefits, plans may offer additional coverage such as:

  • Birth control benefits
  • Breastfeeding benefits
  • Dental coverage

You should never have to pay an extra fee to get help in purchasing coverage. Licensed agents appointed to sell on or your state exchange are the most qualified group to answer questions for you. You can also call the insurance carriers direct, the federal Obamacare website or your state exchange or use a navigator. Only licensed and appointed insurance agents/brokers are allowed to recommend and compare plan benefits of private insurance carriers, with or without a subsidy.

If you are low income and qualified only for Medicaid, you can enroll directly with that agency in your state or through the federal website.

When you register on the government’s federal website, it is crucial that you use an email address you will always have access to. Should you lose access to that account, you will not be able to reset the password or setup a new account. Unless you enroll in a new plan, you would have to make any changes via telephone with

Yes.  While the government has stopped paying for the cost sharing subsidies of the Affordable Care Act, insurers must continue providing them because the subsidies are required by the Affordable Care Act.

While the the Affordable Care Act no longer requires you to have health insurance, it does require carriers to only allow enrollment during an annual open enrollment period. Therefore, individuals can purchase individual insurance coverage on the Individual Market during the annual open enrollment of November 1st through December 15th of each year.

Special Enrollment: You can still sign up for health insurance after the deadline if you meet any of the following qualifying events:

  • change in legal marital status
  • a change in the number of dependants
  • a change in place of residence and the current carrier is not available
  • significant cost or coverage change a change in coverage of a spouse or dependant
  • a COBRA qualifying event
  • legal judgements, decrees and orders
  • entitlement to Medicare or Medicaid

Research shows that the best health plan is one that helps you to not get sick in the first place.   To that end, many insurance carriers have added popular wellness benefits to individual and employer health plans, in hopes to save them and you on healthcare.  Wellness benefits can include anything from preventative medicine, nutrition advice, gym memberships, substance abuse counseling to financial education.  Just about anything that promotes your overall well-being can be considered a valuable “wellness” benefit.