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.

Currently, most people are not required to purchase health insurance. The ACA “shared responsibility payment” and the individual mandate has been eliminated by the Trump Administration for 2019 and beyond. However, some states have established their own individual mandates, so you still may be subject to your specific state tax penalty, if any.

Following is a list of the states, as of 2019, that have mandated residents purchase qualifying health insurance (which is similar to the federal essential health benefits), or face a tax penalty when they file their income taxes.

Updated in 2023…

California – The penalty for not having coverage the entire year will be at least $850 per adult and $426 per dependent child under 18 in the household. The penalty can also be calculated based on percentage; you could also be charged 2.5% of the gross income that exceeds the filing threshold, whichever is greater.

Massachusetts – the tax penalty amount varies depending on your income, age and family size, but note the maximum penalty can be no more than half the price of the lowest premium plan available on the Massachusetts healthcare marketplace.

New Jersey – the tax penalty is $695 for adults and $347.50 for each child, with a maximum family penalty of 2.5% of annual income,. The penalty is capped at three times the adult penalty ($3,661), or the state average cost for a bronze-level plan, whichever is greater.

Rhode Island – the tax penalty is $695 for adults and $347.50 for each child, with a maximum family penalty of 2.5% of income, or three times the adult penalty ($2,100), whichever is greater. The maximum tax penalty is based on the average bronze health plan premiums cost.

Vermont – Vermont requires residents to have qualifying health insurance, but currently, there is no cash penalty for non compliance.

Washington, D.C. – the tax penalty is $700 for adults and $350 for each child, with a maximum family penalty of 2.5% of income, or three times the adult penalty ($2,100), whichever is greater. The maximum tax penalty is based on the average bronze health plan premiums cost.

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.  In fact, the subsidy has been enhanced by the Inflation Reduction Act of the Biden Administration.  According to Kaiser, the subsidy will pay the full costs for a silver plan for consumers with income up to 150% of the federal poverty level (FPL) (originally this plan would have cost families at the same income level about 4% of our annual income).  Note that having access to silver plan also drastically reduces copays and deductibles.

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

Some states have an extended open enrollment period, such as Pennsylvania which runs from Nov 1st to Jan 15th.  Please check with your specific state for accurate open enrollment information.

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.