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Buy Health Insurance Through The Marketplace

How to buy individual health insurance

Last Updated: January 12th, 2018

By Barbara Marquand , Insure.com

Open enrollment for 2018 health plans is over. Unless you qualify for a special enrollment period, you are unable to obtain an individual insurance policy until open enrollment begins in November 2018 for 2019 coverage.

Because of the Affordable Care Act, the health insurance landscape has undergone considerable transformation. You have some advantages as a consumer shopping for an individual health insurance plan that you never had before.

Benefits of new health plans

Health insurance companies can’t turn you down for coverage or charge you higher premiums because you’re sick or have a health condition. Previously, people with health problems faced sky-high premiums to cover a pre-existing condition or couldn’t qualify for an individual health plan at all.

In addition, in order to count as providing sufficient coverage under the Affordable Care Act, health plans now have to offer a comprehensive set of 10 essential benefits, including prenatal and maternity care, hospitalization and preventive care. And they can’t cap the dollar amount of benefits you receive in a year or over a lifetime. The amount you pay out of pocket for health care, however, is capped.

On top of that, you may qualify for premium discounts in the form of tax credits or subsidies to lower your out-of-pocket health insurance costs if your income is low or moderate.

Multiple health care coverage options can be confusing

But those consumer wins don’t make choosing a health insurance plan a snap. You still have to assess your health care needs, review the options, crunch the numbers and choose the plan that makes the most sense for your finances and your health. And you have to accomplish all that in a brand new health insurance frontier.

Let’s review basic ways to get covered:

  1. Group health insurance: Your employer selects the plan(s) and health insurance companies. You enroll at work, usually in the fall during your employer’s open enrollment period.
  2. Individual health insurance: This is a plan you buy on your own. An individual plan can cover just one person or a family. You can buy directly from the best health insurance companies or from your state’s health insurance marketplace, also called an exchange.
  3. Medicaid and the Children’s Health Insurance Program (CHIP): These plans have low income requirements.
  4. Medicare: Mostly for people age 65 and over.

Do your research before open enrollment

You can buy an individual health plan that meets government standards for coverage only during the annual open enrollment period in most states, unless you have a special circumstance, such as getting married or having a baby, which create a special enrollment period.

Don’t wait until the last minute. Give yourself plenty of time to research options and apply. If you miss open enrollment, you could face a tax penalty if you go without coverage.

Assess your health care needs

Your needs should influence the type of plan you choose. The right health plan for your neighbor might not be the right plan for you. Ask yourself some questions to determine your needs:

  • How often do you need to see the doctor?
  • What types of health care will you need in the next year?
  • What prescription drugs do you take?
  • What hospitals and doctors do you want to see?

Investigate health plans on your state marketplace

The federal government’s HealthCare.gov website has links to state health insurance marketplaces. If your income qualifies you for premium discounts or lower out-of-pocket costs, the only way to get them is by purchasing a health plan through the marketplace. Fill out the application to see if you’re eligible for financial assistance and to compare health plans from private insurance companies in your area.

Health plans sold in the marketplaces are categorized according to how much of the health care costs the insurer pays and how much the consumer pays. Generally the higher the out-of-pocket costs — the more you pay in deductibles, coinsurance and copayments — the lower the premium.

Types of health plans

Here are the health plan categories, going from those with the least to most expensive premiums:

  • Bronze: The insurer pays an average of 60 percent of your health care costs; you pay 40 percent.
  • Silver: The insurer pays 70 percent; you pay 30 percent.
  • Gold: The insurer pays 80 percent; you pay 20 percent.
  • Platinum: The insurer pays 90 percent; you pay 10 percent.

Keep in mind these are general categories, and the projected out-of-pocket costs are averages. Plans in the same metal category might achieve the cost split in different ways. Two bronze plans, for instance, might have different deductibles and co-insurance levels, even though their overall out-of-pocket costs are projected to be the same.

Plans in the same metal level might also be structured differently. One bronze plan might be a health maintenance organization, and another might be a preferred provider organization.

You can buy marketplace plans over the phone, through paper applications or online. Some states also hold enrollment fairs.

In addition, catastrophic health plans are available for people under age 30 and those with some type of financial hardship.

Today’s catastrophic health plans are different than the bare-bones plans marketed as catastrophic in previous years. The new catastrophic plans have higher deductibles than traditional plans, but they still cover the essential benefits outlined in the health care reform law, including preventive care. Catastrophic plans generally have lower premiums than bronze plans, but they do not qualify for tax credits to reduce the premium or subsidies to reduce out-of-pocket costs. And, if you qualify to purchase a catastrophic plan, you can buy one only for yourself, not for your entire family. Check with your state’s insurance marketplace for details.

Find out what health insurance companies are offering outside the marketplaces

There are plenty of health plans available directly from insurers, without going through a marketplace. In fact, some insurers are only selling policies outside the marketplace in some states.

Plans sold outside the marketplace are still categorized by metal tiers, and they still must offer the same minimum benefits to qualify as sufficient coverage under the Affordable Care Act. But you might find a plan with a wider network or a better price. Remember, though, you cannot qualify for tax credits for premium discounts when you buy outside the marketplace.

You can purchase health insurance directly from a health insurance company, a website that sells coverage from different carriers or through a health insurance agent. The National Association of Health Underwriters has a “find an agent” tool on its website.

Make sure the health plans you compare outside the marketplace count as sufficient coverage under the Affordable Care Act. Most health plans do, but some, such as temporary or short-term health plans, do not provide all the benefits necessary for meeting the law’s “individual mandate” — the requirement for Americans to have health insurance.

Understand and compare how health plans are structured

Know the differences between a health maintenance organization (HMO), preferred provider organization (PPO), point of service (POS) plan and high-deductible health plan with a health savings account.

  • With an HMO, you choose a primary care physician who coordinates your care, and generally you’re limited to a network of doctors and hospitals. You typically pay a low copayment for each office visit. The plan generally doesn’t cover care outside of the network except in special circumstances.
  • A PPO gives you more flexibility than an HMO. You can see specialists without a referral from a primary care physician. The plan pays a higher percentage of costs if you see doctors in the network, but still provides some coverage for services outside the network.
  • A POS plan is a little of both. It operates like an HMO if you stay within the network, but gives you the option of using out-of-network doctors. Typically a POS plan requires you to get a referral to see a doctor outside of the network.
  • A high-deductible health plan paired with a health savings account, or HSA, features a (as the name implies) high deductible before coverage begins. You can use money from the HSA for out-of-pocket medical expenses. Contributions you make to the account are tax deductible, and unused money rolls over to the next year. You get to keep the account even if you change health plans, and you can use the money for non-medical expenses in retirement.

Compare provider networks and benefits

Dig into the details of what the health plans cover. For instance, how will the plan cover the prescription drugs you take? Make sure the health care providers you want to use are in the plan’s network. Otherwise you will pay more out of pocket or may not have coverage to see them.

Crunch the numbers

In addition to reviewing the premium you’ll pay for the plan, estimate how much you’ll pay out of pocket for the amount of health care you expect to use in the next year.

If you rarely need medical care, it probably makes more sense to choose a plan with a higher deductible and lower premium than to pay a high premium for a plan with a low deductible.

Health Insurance Marketplace Calculator

Financial Help for Health Insurance Coverage through Marketplaces

Published: Nov 03, 2017

about this tool

Enter Information About Your Household

The Health Insurance Marketplace Calculator is based on the Affordable Care Act (ACA) as signed into law in 2010, and subsequent regulations issued by Health and Human Services (HHS) and the Internal Revenue Service (IRS).

Premiums displayed in the calculator’s results are based on actual exchange premiums in 2018 dollars. Premiums were obtained through a review of insurer rate filings to state regulators as well as data published by HHS. The silver premium is the second-lowest cost silver premium available in the rating area of the entered zip code and the bronze premium is the lowest-cost bronze plan in the rating area of the entered zip code. Not all plans are available in all parts of the rating area, so actual premiums may vary depending on plan availability.

The premium is adjusted for family size and age of the user. Premiums in the calculator vary by age within the three to one limit specified in the law, using age factors from proposed regulations issued by HHS (or, state specific age factors where states have adopted them). The calculator does not display a tobacco surcharge. However, in most states, insurers can charge a tobacco surcharge of up to 50% of your total premium, and tax credits do not apply to the surcharge. Actual tobacco surcharges will vary by plan and some states do not permit insurers to vary premiums by tobacco status.

Frequently Asked Questions

If you have questions about how the health reform law will affect you and your insurance options, please go to Healthcare.gov, or contact their Help Center at 1-800-318-2596 if you have questions that cannot be answered on their website. You can also contact your state’s Consumer Assistance Program, Exchange, or Medicaid office with questions about eligibility and enrollment.

The Kaiser Family Foundation is not able to provide individual advice on your insurance options. However, we do provide some answers to frequently asked questions below, along with more detailed questions and answers in our Health Reform FAQ page.

I am having difficulty viewing or understanding my results. What should I do?

It could be that you are using an older version of Internet Explorer or Firefox. Try updating to a newer version of your web browser. Not sure which browser version you are running? Check here for IE or here for Firefox. If you continue to have technical problems with the Calculator after updating your browser, please contact the Kaiser Family Foundation.

Please note that we are not able to provide individual advice or assistance understanding your results. If you have additional questions, we suggest that you contact Healthcare.gov or your state’s Health Insurance Marketplace for more information.

Has the calculator been updated for 2018?

Yes, the calculator now shows premiums for 2018 in all states.

Does the calculator provide definitive results for what I will pay?

No. The calculator is intended to show you an estimate of how much you may pay and the amount of financial help you may be eligible for if you buy coverage through the Health Insurance Marketplace. To find out if you are eligible for financial assistance and to sign up, you must contact Healthcare.gov, your state’s Health Insurance Marketplace, or Medicaid program office.

Although the Health Insurance Marketplace Calculator is based on actual premiums for plans sold in your area, there are several reasons why your calculator results may not match your actual tax credit amount. For example, the calculator relies completely on information as you enter it, whereas the Marketplace may calculate your Modified Adjusted Gross Income (MAGI) to be a different amount or may verify your income against previous year’s data.

How do health insurance subsidies work?

Subsidies are financial assistance from the Federal government to help you pay for health coverage or care. The amount of assistance you get is determined by your income and family size. There are two types of health insurance subsidies available through the Marketplace: the premium tax credit and the cost-sharing subsidy.

The premium tax credit helps lower your monthly expenses. This subsidy is available to people with family incomes between 100% and 400% of the poverty level who buy coverage through the Health Insurance Marketplace. These individuals and families will have to pay no more than 2.01% – 9.56% of their incomes for a mid-level plan (“silver”) premium. Anything above that is paid by the government. The amount of your tax credit is based on the price of a silver plan in your area, but you can use your premium tax credit to purchase any Marketplace plan, including Bronze, Gold, and Platinum plans (these different types of plans are described below). You can choose to have your tax credit paid directly to the insurance company so that you pay less each month, or, you can decide to wait to get the tax credit in a lump sum when you do your taxes next year.

Cost-sharing subsidies (also called “cost-sharing reductions”) help you with your costs when you use health care, like going to the doctor of having a hospital stay. These subsidies are only available to people purchasing their own insurance who make between 100% and 250% of the poverty level (and some Native Americans). If you qualify for a cost-sharing subsidy, you would need to sign up for a silver plan to take advantage of it. Unlike the premium tax credit (which can be used for other “metal levels”), cost-sharing subsidies only work with silver plans. With a cost-sharing subsidy, you still pay the same low monthly rate of silver plan, but you also pay less when you go to the doctor or have a hospital stay than you otherwise would.

For more information, read the actuarial value question below. If you have more specific questions about your subsidy, you can consult our FAQ pages or contact an assister or navigator through Healthcare.gov or your state’s Marketplace.

What is included in household income? How do I know what to enter for my income?

The Health Insurance Marketplace Calculator allows you to enter household income in terms of 2018 dollars or as a percent of the Federal poverty level. Household income includes incomes of the person who pays taxes, the spouse, and children, known as dependents on tax returns. For the purposes of the calculator, you should enter your best guess of what your income will be in 2018.

When you go to Healthcare.gov or your state’s Health Insurance Marketplace website, it will walk you through the steps to calculate your household income based on wages, salary, foreign income, interest, dividends, and Social Security. The calculation does not include income from gifts, inheritance and some other income sources. For more information, see this table of what income sources to include or not include.

What is the Federal poverty level?

The Federal poverty level varies by family size. For Marketplace coverage in 2018, the poverty level used is $12,060 for a single adult and $24,600 for a family of 4.

What is Medicaid? How does it relate to financial help through the Health Insurance Marketplace?

Medicaid is a health insurance program (offered through a partnership between states and the Federal government) that helps with medical costs for some people who have limited income and resources. Medicaid programs vary from state to state, but most health care services are covered at little or no cost. If you are eligible for Medicaid, then you would not be eligible for subsidies in the Marketplace and would instead need to sign up for Medicaid.

As a result of the health care law, states have the option to expand Medicaid eligibility to all people with incomes below 138% of the poverty level. Currently about half of states have decided to expand their Medicaid programs and the other half have not. If you live in a state that has not expanded Medicaid and you expect your income to be above the poverty level, then you may be eligible for subsidies through Healthcare.gov or your state’s Marketplace. If you expect that your income next year will be below the poverty level, then you may not be eligible for assistance through the Marketplace. However, it is possible that you may still qualify for Medicaid under your state’s eligibility criteria, particularly if your income is very limited and you have children, are pregnant, or have a disability.

The Health Insurance Marketplace Calculator takes into account whether or not your state has decided to expand Medicaid, so you can use this tool to estimate of your eligibility for Medicaid. Again, keep in mind that – even if your state did not expand Medicaid – you or some members of your family may still be eligible for Medicaid. To find out if you qualify for Medicaid, contact Healthcare.gov, your state’s Marketplace, or your state’s Medicaid program office for information about eligibility and enrollment.

If I am eligible for Medicare can I still sign up on the Marketplace?

No, you cannot sign up for Marketplace coverage if you are eligible for Medicare. Most people age 65 and older are eligible for Medicare, which is health insurance program run by the federal government. If you are eligible for Medicare, even if you did not choose to enroll in Medicare, you would not be able to purchase Marketplace coverage.

When using the Health Insurance Marketplace Calculator, if some members of your household are eligible for Medicare and others are not, you should enter your full household size (including those who are eligible for Medicare) in Question #5. For the following question (#6), please enter only those family members who are signing up for Marketplace coverage (do not enter adults who are eligible for Medicare in Question #6).

If you are over the age of 65 but not yet eligible for Medicare due to immigration status, you may be eligible for Marketplace coverage. You can use the Health Insurance Marketplace Calculator by entering your age as 64.

Does my age or health status affect how much I pay for health insurance?

As a result of the health care law, insurance companies cannot deny you coverage or make you pay more for your health coverage based on your health.

In most states, older people will still pay more for health insurance than a younger person. The health reform law sets a new limit that people aged 64 and older can be charged no more than 3 times that of a 21 year old. Children under age 21 have slightly lower premiums and families with more than three children under the age of 21 will be charged premiums for no more than three children.

Vermont and New York are currently the only states that require all adults in a given plan to be charged the same rate. If you live in one of these states, the Health Insurance Marketplace Calculator will calculate your premiums according to your state’s rules.

Does where I live affect how much I pay for health insurance?

Yes. The cost of health insurance (your monthly premium) varies quite a bit by state, and even within regions of a state. This is because of several factors, such as the cost of living and cost of health care services in your area.

Your premium tax credit is tied to the cost of insurance in your area. If you live in a high-cost area, you may be eligible for more financial assistance.

Premiums in the Health Insurance Marketplace Calculator are actual premiums in your area. It is possible that some plans may not be available in your particular zip code or county, though. For this reason, you may get slightly different results when you apply for subsidies through Healthcare.gov or your state’s Marketplace.

If I use tobacco, can this affect how much I pay for health insurance?

Yes, in most states, insurers can charge people who use tobacco a higher premium (this is called a “tobacco surcharge”). Currently, only six states (California, Massachusetts, New Jersey, New York, Rhode Island, and Vermont) and the District of Columbia do not allow private health plans to charge higher premiums for people who use tobacco. (Medicaid programs have different rules; these programs do not allow tobacco surcharges in any state).

Under the health reform law, private insurers can charge tobacco users no more than 50% more per month than who do not use tobacco. The health law also makes clear that financial help through the Health Insurance Marketplace cannot be used to cover the portion of the premium that is due to a tobacco surcharge.

The Health Insurance Marketplace Calculator does not adjust your results based on tobacco use because tobacco surcharges vary quite a bit from plan to plan. Even in states that allow it, some insurers choose not to charge higher prices for tobacco users or charge relatively low surcharges. For this reason, the calculator warns you when you might face higher prices, but to find out your true costs, you will need to go to Healthcare.gov or your state’s Marketplace.

What are Bronze and Silver plans?

When you buy coverage through the Health Insurance Marketplace you can choose between four levels of coverage: Bronze, Silver, Gold, and Platinum. The levels are based on how much financial protection the plans offer you when you get sick or need medical care.

Bronze plans will have the lowest monthly payments (premiums), but if you get sick or have an accident, your share of these costs (deductibles and copayments) will be higher. Silver plans are more protective and will have higher monthly payments, but you’ll likely spend less when you get medical care. Gold and platinum plans have the highest monthly payments, but you’ll have fewer additional costs.

The Health Insurance Marketplace Calculator shows the cost of silver and bronze plans in your area. Silver plans are important because these are used as a “benchmark” for calculating how much assistance you are eligible for. The silver premium shown in the calculator is the second-lowest-cost silver plan in your area.

The Health Insurance Marketplace Calculator will also show you the price of the lowest-cost bronze plan in your area. Bronze plans are the lowest level of coverage that most people are required to have under the health law. If a Bronze plan is still unaffordable to you even after financial assistance, or if you are under the age of 30, you may purchase a catastrophic plan. The calculator will tell you when catastrophic coverage may be an option to you.

For more information on the difference between bronze and silver plans, see the question on actuarial value, below.

What are my options if I have job-based health coverage?

With most job-based health plans, an employer pays part of your monthly or yearly costs (premiums). In general, people who qualify for health insurance through their job are not able to get financial assistance through the Marketplaces.

However, if your employer’s coverage is either unaffordable or doesn’t meet the health care law’s “minimum value” requirement, then you may be eligible for financial help to purchase through the Marketplace. “Minimum value” means your employer plan pays at least 60 % of the total cost of medical services. Your employer can tell you whether the insurance plan it offers meets minimum value. It also can provide you with information to determine if the plan is considered affordable to you.

When using the Health Insurance Marketplace Calculator, you can answer “No” to Question #4 if your employer’s coverage is unaffordable or does not meet the minimum value requirement.

What is actuarial value and how does it affect how much I pay for insurance and health care?

While health insurance may pay for most of a covered medical service, you generally still pay some of the cost when you go to the doctor or have a hospital stay. Actuarial value is the percentage of total covered medical expenses that are paid for by the insurance company, on average, for a typical population. The higher the actuarial value, the more financial protection the plan is likely to offer you when you get sick or need medical care.

For example, if a plan has an actuarial value of 70%, then the insurance company will pay about 70% of the total medical expenses. Together, you and everyone enrolled in the plan would pay the remaining 30% of the total bills. This does not mean that you personally will pay 30% of your expenses. Rather, this is an average across everyone enrolled in the plan. Your own costs will vary substantially from this amount, depending on how much care you use.

While actuarial value doesn’t tell you exactly what you will pay, understanding it can help you pick which level of plan is right for your health needs. Bronze plans, which are the lowest level of coverage most people are required to maintain, have an actuarial value of about 60%. Bronze plans will have low monthly premiums, but if you get sick or have an accident you will pay more in medical bills. Silver plans are more financially protective and have an actuarial value of about 70%. Gold and Platinum plans have the highest monthly payments but also are the most protective if you get sick or need a lot of medical care: they have actuarial values of about 80% and 90%, respectively. Once you pick which level of coverage is right for you, you can compare plans of a similar value side-by-side.

If your income is very limited, you may qualify for a cost-sharing subsidy if you sign up for a silver plan (these subsidies are explained more above). With a cost sharing subsidy, you still pay the same low premium of a silver plan, but get more value out of it when you get sick and need health care. Normally silver plans have an actuarial value of 70%, but with the cost-sharing subsidy, your silver plans’ actuarial value will range from 73% to 94% (depending on your income). This means you will likely pay less when you go to the doctor or hospital than you otherwise would with a silver plan.

The Health Insurance Marketplace Calculator estimates whether you may be eligible for cost staring subsidies. If you are likely eligible for a cost sharing subsidy, the calculator also shows what your silver plan’s actuarial value would be.

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