What is health insurance?
Health insurance is a binding agreement that you and/or your family enter into with a service provider—oftentimes, a health insurance company. Under the agreement, you generally sign up for a plan of medical service that you can access for treatment and care. You pay for the plan, and in return the service provider agrees to pay part or all of your medical costs when you seek medical attention.
Why do I need to purchase health insurance?
Nobody plans to get sick or hurt. Health insurance is there to protect you and your family from the potential high costs of treatment and care that may arise should you unfortunately fall ill or get into an accident.
Did you know an unexpected trip to the hospital could cost you and your family nearly $2,000 a day? The hefty price tag does not even include prescription drugs or medical procedures, which easily can add up to tens of thousands of dollars. It’s no joke that the leading cause of all bankruptcies in the United States is soaring medical bills. Health insurance can protect you from an unexpected financial hit due to accident or illness.
Who is required to purchase health insurance?
As of January 1, 2014, most individuals and families in the United States are required to carry health insurance or pay a fee for going without coverage.
If you receive health insurance through work, then you most likely don’t have to do a thing.
If you are on an assistance program such as Medicaid, Medicare, or TRICARE, then you’re likely covered.
But if you or your family currently do not have health insurance, you are able to purchase a private plan through a Health Insurance Marketplace that meets you and your family’s health and budgetary needs.
Why should I buy a plan in the marketplace?
What does my insurance plan cover?
Almost every health insurance plan offered in the United States, whether on or off the Health Insurance Marketplace, will be required to cover what are known as Essential Health Benefits (EHBs). These include:
- Preventive care
- Emergency care
- Ambulatory services
- Laboratory services
- Prescription drugs
- Rehabilitative and habilitative care
- Behavioral and mental health
- Maternity and newborn care
- Pediatric care, including vision and dental care
In addition, most plans are required to cover preventive services without charging you a co-pay or co-insurance, even if you have not yet met your yearly deductible. These include but are not limited to:
- Annual checkups
- Screenings for blood pressure, cholesterol, and diabetes
- Cancer screenings
- Immunization vaccines
What is a Health Insurance Marketplace?
A Health Insurance Marketplace, also known as a Health Exchange, is a platform through which individuals and families can shop for health-care coverage.
There are 51 Health Insurance Marketplaces throughout the country, one for each state and the District of Columbia. Through the Health Insurance Marketplace, you are able to:
- Shop for and compare health plans offered by private insurance companies,
- Find out if you qualify for tax credits and subsidies that may help you pay for a private health plan, and
- Sign up for coverage.
Note that the Health Insurance Marketplace may be known by other names depending on where you live (e.g. Covered California, Kynect, DC Health Link).
Why should I buy a plan in the marketplace?
What type of plan is right for me?
Qualified health plans offered through the Health Insurance Marketplace will fall into one of four metallic categories:
As the names suggest, these categories correspond to the level of coverage that a plan provides.
Bronze plans offer the lowest cost in terms of monthly premiums, but come with the least amount of coverage. Depending on how much service and attention you and your family need, you could be paying more in the long run in out-of-pocket costs such as co-pays and deductibles.
On the other end of the spectrum, Platinum plans come with more expensive monthly premiums but also cover more of the costs of medical services.
What is the best plan for one person or family may not be the best plan for another. Plan rates and coverage vary by category, provider, and geographic area. It is recommended that you speak with a licensed agent at the number above to determine what is best for you and your family.
Do I qualify for free coverage? What about help to pay for my insurance?
Several factors are used to determine if you qualify for help to pay for your health insurance costs. Some factors include:
- Family size,
- Household income,
- Whether or not you receive affordable coverage through work and/or a program such as Medicaid or Medicare, and
- Where you live.
If you currently receive health insurance through your job, then you are likely all set and do not have to do anything. If you are on Medicare or Medicaid, then you may not have to do anything either. However, if an insurance plan offered by your employer is not affordable (in other words, if your share of monthly premiums exceeds 9.56% of your individual income), then you may shop on the Health Insurance Marketplace, where you might qualify for help to pay your costs.
Use our estimator to find out if you may qualify for help and what you may expect to pay for a private health insurance plan.
How do I know if I qualify for financial help/premium tax credits?
How does financial help work to lower my costs?
Help is available in two ways. You may be eligible for tax credits to help pay your monthly premiums, and subsidies to help with some of your out-of-pocket costs.
Individuals and families who obtain coverage through the Health Insurance Marketplace may be eligible for Advance Premium Tax Credits (APTCs). These tax credits are used to lower the costs of your monthly premiums.
Furthermore, if your income is below a certain threshold and you select a Silver plan, you may qualify for Cost Sharing Reduction (CSR) Subsidies that will go toward paying your out-of-pocket costs, such as deductibles and co-pays for doctor visits.
Do I make payments to the insurance company or do I pay the Health Insurance Marketplace? What about when I go see a doctor?
Once you are enrolled in a health plan, you generally receive a bill from the insurance company every month for monthly premiums. The amount on the bill should only reflect your portion of the bill – what you owe the insurance company each month. If you qualify for tax credits that lower the cost of your monthly premium, this amount should be deducted from your premium. The insurance company will receive this payment directly, so you do not need to worry about it.
When you go see a doctor or another health care provider, you will need to show them your insurance card. You may owe co-pays and/or deductibles, depending on the plan you select and how much financial help you receive. You will pay your doctor or health care provider directly for your share of the costs while your insurance company pays its share.
When can I sign up for coverage?
You can sign up for health insurance at any time. However, in order to enroll in a plan through the Health Insurance Market place or qualify for and receive help to pay your monthly premiums and out-of-pocket costs, you must sign up during open enrollment periods, unless you meet special criteria.
To enroll in a plan through the Health Insurance Marketplace outside of open enrollment, you must meet one of these eligibility requirements: If you or someone in your family experiences a life-changing event, such as a marriage or divorce, birth or adoption of a child, relocation, or change in jobs, then you may have up to 60 days to enroll in new coverage. Find out more here.
To get coverage through the Health Insurance Marketplace for 2016, sign up during the open enrollment period from November 2015 through January 2016.
What should I do before I sign up?
When you apply for or renew your coverage in the Health Insurance Marketplace, you will need to provide some information about you and your family, including income, any insurance coverage you currently have, and some additional items.
Here is a list of items that may be useful to have handy:
- Home and/or mailing address of you, your family, and anyone else for whom you are applying for coverage
- Social Security numbers
- Income information (e.g. pay stubs, W-2, 2013 income tax return)
- Information about any current health insurance you or anyone in your family already has
- Documentation information for non-U.S. citizens (e.g. naturalization certification, permanent residency card or “green card,” work or student visa, residency permit)
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