5 Questions to Ask When Choosing an #ACA Plan

The Health Insurance Marketplace offers different plan types to meet a variety of needs and budgets. Most people qualify for financial help to make health coverage affordable. Compare plans based on what’s important to you, and choose the combination of price and coverage that fits your needs. Ask yourself these 5 questions as you shop for Marketplace coverage. 

1. Can I get help paying for Marketplace coverage? 

You may be able to qualify for financial help to lower the cost of your coverage. Eight out of ten people who signed up for health coverage at HealthCare.gov qualified for financial help to make their coverage more affordable. In fact, most people found plans that were $75 or less per month. After you fill out a Marketplace application, you’ll learn if you’re eligible for financial help to lower the cost of your monthly premiums and care. This financial help will also apply to your dental coverage if it’s a part of your health plan. 

2. What benefits do health plans cover? 

All health plans in the Marketplace offer the same set of items and services known as “essential health benefits.” These benefits cover things like doctor’s visits, prescriptions, hospitalizations, pregnancy, and more. 

Health plans can offer other benefits, like vision, dental or medical management programs for a specific disease or condition. However, specific benefits may be different in each state. Even within the same state, there can be small differences between plans. As you compare plans, you’ll see what benefits each plan covers. This will be helpful if you have specific health care needs. 

3. How do I find a plan that fits my budget and meets my needs? 

Finding a good health plan means balancing how much you pay each month with how much health care you think you and your family are going to need during the year. If you’re healthy and don’t go to the doctor very often, then a plan with a low monthly premium (the amount that must be paid for your coverage) would probably cost you the least. But if you need to go to the doctor a lot, or you need a lot of expensive prescriptions, you should look at plans where the cost of getting care, or how much you pay out of your own pocket (like coinsurance or a copayment), will be lower. When you shop for plans in the Marketplace, they’re put into 5 categories (Bronze, Silver, Gold, Platinum, and Catastrophic) to help you sort out what you can afford based on your health care needs. The category you choose affects the cost of your monthly premium, and what portion of the bill you pay for things like hospital visits or prescriptions – but it doesn’t reflect the quality or amount of care plans provide.

Health Plan Categories 

Bronze: Your health plan pays 60% of the total average costs of care. You pay about 40%. 

Silver: Your health plan pays 70% of the total average costs of care. You pay about 30%. 

Gold: Your health plan pays 80% of the total average costs of care. You pay about 20%. 

Platinum: Your health plan pays 90% of the total average costs of care. You pay about 10%. 

*Catastrophic: Your health plan pays less than 60% of the total average costs of care. * NOTE: Catastrophic Plans are available only to people under 30 years old or to people who have a hardship exemption. To learn more about “hardship exemptions,” visit HealthCare.gov/fees-exemptions/hardship-exemptions.

Although all plans in the Marketplace cover a core set of benefits, the amount you pay will be different from plan to plan. In general, if your monthly premium payments are low, the cost of getting care, or how much you’ll pay out of your own pocket for things like prescriptions or hospital stays, will be higher. If you pay more each month for your premium, those other costs will be lower.

With a cost-sharing reduction, you’ll pay lower deductibles (the amount you pay before your insurance starts to pay for care you get), copayments, and coinsurance. You’ll basically get the lower out-of-pocket costs of a Gold or Platinum plan while paying a Silver plan premium. You can choose a plan from any plan category, but you get these savings on out-of-pocket costs only if you enroll in a Silver plan.

4. How does dental coverage work in the Marketplace? 

After you complete your Marketplace application and get your results, you can then view health plans that include dental coverage. Children’s dental coverage in the Marketplace is an essential health benefit. This means that if your child is 18 or younger, dental coverage must be available as part of a health plan or as a stand-alone dental plan. Adults don’t have to be offered dental coverage, but many Marketplace plans offer it as part of a plan or as a stand-alone dental plan. 

Marketplace dental plans are put into 2 plan categories based on how you and the plan can expect to share the dental care costs for children (the categories only apply to the child dental coverage essential health benefit). 

Low: Your dental plan will pay about 70% of dental costs for children. 

High: Your dental plan will pay about 85% of dental costs for children. 

The dental plan category you choose affects the total amount you’ll likely spend out-of pocket for your child’s dental care during the year. 

Dental coverage is offered as part of some health plans, but not all of them. If you decide you want dental coverage and your plan doesn’t offer it, you can enroll in a separate stand-alone dental plan at the same time you enroll in a health plan. Some dental plans only cover children and others cover families. You should review the plan details to make sure the benefits you want are included in the plan.

5. Do I expect a lot of doctor visits, dental care, or need regular prescriptions? 

If you do, you may want a Gold or Platinum health plan, and a High level dental plan. They likely have higher premiums, but you could pay less for each visit, prescription, or other medical and dental service. If you don’t, you may prefer a Bronze or Silver plan, and a Low dental plan. Your monthly premiums will likely be lower, but you’ll likely pay more of the cost when you see a doctor. 

Need help? 

If you have questions or need help, visit Localhelp.HealthCare.gov. You can find someone who can help you in person. TTY users should call 1-855-889-4325.