This very basic description of health-insurance options can be a useful starting point for any American citizen or immigrant who is uninsured or whose insurance provides limited benefits and protections. The information was gathered from Healthcare.gov and other sources, but it may not be completely up to date.

DEFINITIONS  ☰ 


INSURANCE

Health plan (or policy) A legal agreement between an insurer and insured (person or family). The insurer provides and/or pays for all or part of the insured’s expenses for the length of the plan. Plans usually last one year but can be renewed.

Enrollee (policy holder, subscriber, member) Person covered by an insurance plan.

Premium The amount you pay your insurer every month.

Deductible The amount of your healthcare expenses that you must pay each year before your insurer starts to pay part of them.

Coinsurance Once you pay the deductible, you are only responsible for part of any additional medical expenses that are covered by the plan. How much that part is depends on the plan you have.

Copays (copayments) Some smaller expenses you must pay when you receive services, tests, or prescriptions.

Out-of-pocket The money you pay for the deductible, coinsurance, and copays (but not your premiums). Your out-of-pocket maximum (or limit) is the most you have to pay during the year of the plan. The OOP maximum for Affordable Care Act plans in the 2015 enroll­ment was only $6,850 for an individual and $13,700 for family.

Covered or excluded services  A list of things or treatments that are part of (or are never part of) what the insurer will provide or pay for.

Annual limits How much your insurer will pay for some covered services each year (for example, certain prescriptions). You pay the full cost of anything after that.

MEDICAL

Provider Medical professional or organization that provides medical services.

Primary-care physician The doctor you see for your annual physical exam and the treatment of minor problems. Primary-care providers include nurse practitioners and others who provide basic health care or help patients obtain it. Specialists treat specific problems or areas (for example, the eyes) and have related skills (for example, surgery).

Network The doctors, hospitals, and other providers that have contracts with an insurer. If you go out of network to other providers, you must pay part or all of the outside provider’s fees (depending on the type of plan). Some plans do not apply this to out-of-network emergency rooms.

Referral Some plans do not allow you to see a specialist or have a test without the permission of your primary-care physician (or a specialist you were referred to).

Managed care Managed-care organizations (MCOs) can deal with all of your medical needs with a network of providers. Some have most of their doctors and facilities in one place, others have contracts with providers in the area.

Most MCOs are one of these types: Health Maintenance Organization (HMO), Point-of-Service (POS), Exclusive provider organization (EPO), and Preferred Provider Organization (PPO). Some insurers offer High Deductible Health Plans (HDHPs), which allow you to choose any providers you wish but have very high deductibles.

MANAGED-CARE ORGANIZATIONS COMPARED
 TYPE OF ORGANIZATION  HMO PPO EPO POS
You must have a primary‑care physician yes no no yes
You must get referrals yes no no yes
If you go out of network, you pay all some all some
 

THE AFFORDABLE CARE ACT  ☰ 


The Affordable Care Act (ACA), also known as Obamacare, made it possible for millions more Americans to finally get health insurance.

THE ESSENTIAL BENEFITS

ACA plans and recently created private plans must cover ten “essential benefits.”

Grandfathered plans Plans that were created before March 23, 2010, do not legally have to provide some of the benefits and protections that ACA plans must provide.

THE PLANS

There are four types (levels) of plans, each with different prices for the premiums and different coinsurance percentages. For example, Bronze Plans have the lowest premiums but high deductibles. Your coinsurance will be 40% of any additional expenses until you have paid the annual out-of-pocket maximum (OOP). Your insurer pays the other 60% and any other expenses during that year. (The out-of-pocket maximum in 2015 was $6,850 for an individual or $13,700 for family.)

ACA PLANS COMPARED
PLAN LEVELS BRONZE

SILVER

GOLD

PLATINUM

Premiums you pay  lowest

next lowest

higher

highest

Coinsurance you pay  40%

30%

20%

10%

Coinsurance your insurer pays  60%

70%

80%

90%

BUYING A PLAN

Who U.S. citizens, U.S. nationals, and legal immigrants can buy ACA plans.

Where Your state’s ACA Marketplace Exchange. If there is none, go to HealthCare.gov.

When Open Enrollment begins in November and ends some time in January. Plans bought before December 15th start on January 1st. (After that, February 1st.) At any other time, you can only buy a new plan if you had been insured and your status changed. Examples of status changes include losing your job (and employer-provided insurance), getting divorced, having a baby, or moving to another state.

If your status changes, you have 60 days to apply for ACA insurance. Call your Exchange immediately.

How much Costs vary around the country. Prices are usually lower in states where more insurers compete, but local health-care costs also affect prices. And even though every state government has the power to deny unreasonable rate hikes, some refuse to.

Subsidies You may be able to get financial assistance paying your premiums if your house­hold income is between 100% and 400% of the federal poverty level. The amount of that assistance will be sent directly to your insurer each month.

Watch out for scams Criminals have set up fake state and federal exchanges. Both fake and real insurers send misleading emails suggesting they are part of the ACA or leading people to believe they will receive a subsidy.

HealthCare.gov does not provide a clear on-site explanation of what it is or what to expect. The suggestions in this section may help you understand the federal and some state Exchanges. (The links and information may already be out of date, so read the Heathcare.gov site carefully.)

The Steps to Buying a Plan

  1. Decide How much coverage will you need and how much can you afford to pay.
  2. Prepare Find and organize all the information you will have to provide.
  3. Compare Take a very careful look at the plans.
  4. Create an account Name and address, a username, security questions.
  5. Apply Answer questions about citizenship and household income.
  6. Enroll Select the plan that best fits your situation. Pay the first premium.
  7. Follow up Confirm that the enrollment has gone through.

Deciding and Preparing

Don’t wait until the Open Enrollment Period begins. Even though the plans will not be available to study until then, you should complete the steps 1 and 2 long before that. A list of the required information is on the mail-in application.

Make sure everyone in the house­hold has a social-security number, even babies. Getting a number could take a while, so apply now.

You can get a free email account from Yahoo!, Google, or other company.

Comparing

If you were insured and your status changed, you can preview the plans when it happens. But new buyers and those who have plans should not preview them before the November enrollment period start date because they may change.

Study the plans carefully. Find the ones that are most likely to fill your needs so you can quickly choose one when you reach the enrollment stage and know the final details.

Don’t base your choice on premium costs alone. You won’t know the real cost of a plan until you find out what all the copays, annual limits, and other expenses are. Look for plans that provide the treatments, drugs, and other things you need.

The four plan categories have many things in common, but some offer more benefits. You’ll find those in the Other Covered Services section near the end of the Summary of Benefits.

You will have to supply some basic information to see the plans, but the premium price you will see at this stage will be an estimate, not the final price.

Click the details button to see what else the plan offers. The new page will list the costs of the copays, deductibles, and out-of-pocket expenses. If the plan seems interesting, use the following links to download more information:

Summary of Benefits: what services are included and what they cost.

Provider directory: their network of physicians and medical centers.

Formulary: list of the drugs covered by the plan.

Plan brochure: general information about the plan.

Use these worksheets to help assess the plans.

Creating an Account

This section only provides some hints to help you navigate. Some of the security questions ask for things anyone can find out, so supply impossible answers. (For example, substitute 1901 as the date you were married or poison ivy as your favorite radio station.) Good security answers help protect you against the very real danger of medical identity theft. [ 1 ]

Confirmations of the next three steps may take minutes or hours to go through. Don’t sit there waiting for them, just check the page from time to time.

It can take a fairly long time to complete the next two steps, but you don’t have to do it all at one time. You can log out and log back in at any time. If you have completed the application stage, select Find my existing application.

 

Applying

For help understanding the site (and for translations of it in many languages):

 
https://www.healthcare.gov/contact-us/
 

1‑800‑318‑2596  or TTY: 1‑855‑889‑4325

After completing the application, you will find out if you qualify for a plan, or a plan and a subsidy, or Medicaid and/or CHIP (which are explained in the next section).

If you think the results are not correct, you can appeal them.

Enrolling

The tax credit (subsidy) will be divided in 12 equal parts and sent directly to the insurer by the Exchange each month. If you expect your household income will be much higher next year (which might reduce your subsidy), have the Exchange use a smaller amount. For example, a subsidy of $1200 would pay $100 a month. If you use it all and earn too much, you might have to pay some of the money back. But if you apply only $80 each month to the premium, and earn more money than you expected, you might not have to pay anything. Or, if you don’t earn too much, you can use the other $240 to pay your taxes—or have it added to your tax refund.

Following up

A few days after you have paid the first premium, you should log onto your account and click on your application. My Coverage page will have details about your enrollment. If you have not yet been enrolled, ask the insurer if they received your premium. If they did, ask when you will be enrolled. If you haven’t been enrolled yet, call back every day until you are.

You will receive membership cards and other information in the mail. If you find any errors or have any questions, contact the insurer.

PRIVATE INSURANCE

You have have insurance, but you do not have to buy it from the Marketplace. However, you should be very careful if you buy directly from an insurance company. Avoid grandfathered plans, which may cost less but rarely offer as much health or economic protection as the Marketplace plans. [ 2 ]

Watch out for bogus companies. They will take your money but cannot be found when there are bills to pay. Some use names that resemble legitimate firms and may even sell their products through licensed agents. [3]

Group Plans

Some professional and social organizations offer group insurance plans. The cost of membership and insurance might be less than an individual plan.