Pick A Plan Employer Marketplace | MyHealthcareFinances

What are some Important Words to Know?

Monthly Premium

The amount that you pay for health insurance, which is usually billed monthly.
You must pay the premium each month, even if you don’t visit a health care provider or use any other healthcare service.

Annual Deductible

The amount you must pay for covered medical care or prescription drugs before your insurance plan starts to pay.
Usually, covered costs are added toward your deductible during your plan year and then start over the next year.

Co-payment (Co-pay)

A fixed dollar amount you pay when you receive medical care or prescription drugs.

Co-Insurance

A percentage of your covered healthcare costs that you pay.
Co-insurance usually only applies after you have reached your deductible.

Out-of-Pocket Maximum

A fixed dollar amount that is the most that you will have to pay for your covered medical care and prescription drugs out-of-pocket during the year.
Once you reach your out-of-pocket maximum, your insurance pays 100% of your covered medical costs for the rest of the year.
Generally, all payments for in-network services count toward your out-of-pocket maximum. This does NOT include your monthly premiums.

Additional Information

For a closer look at health insurance financial terms and prescription drug terms, visit the “Words that Matter for Health Insurance” page (https://www.myhealthcarefinances.com/health-insurance#WordsThatMatter)

Marketplace Plans

The Patient Protection & Affordable Care Act (ACA) created a new way to find and buy private health insurance plans for individuals and families: State Health Insurance Marketplaces

State Health Insurance Marketplaces are also called “exchanges”
Marketplaces for most states are run by the federal government:
- https://www.healthcare.gov/
- or 800-318-2596.
Some states run their own Marketplaces and may have a different name. Click here to find your state’s Marketplace: https://www.healthcare.gov/marketplace-in-your-state/

Eligibility

To be eligible to buy a health plan through the Marketplace, you:

1. Must live in the United States
2. Must be a U.S citizen or be lawfully present in the U.S.
3. Can’t be incarcerated

If you have Medicare, you’re not eligible to use the Marketplace to buy a health or dental plan

Plan Levels

Plans sold through the Marketplace are grouped by their cost-sharing, broken into levels: bronze, silver, gold, and platinum

Plan Level
(Cost-Share)

Bronze
(Insurance Pays 60%
You Pay 40%)

Silver
(Insurance Pays 70%

You Pay 30%)

Gold
(Insurance Pays 80%
You Pay 20%)

Platinum
(Insurance Pays 90%
You Pay 10%)

Monthly Premium

$$$

$$$$

Deductibles/
Out-of-Pocket Costs

$$$$

$$$

According to HealthCare.gov, this may be a good plan for people who…

Want a low-cost way to protect themselves from worst-case medical scenarios, with a low monthly premium, but higher costs for routine care

Qualify for extra cost reductions, or those who are willing to pay a slightly higher monthly premium than a bronze plan to have more routine care covered

Are willing to pay more each month to have more costs covered for medical treatment, particularly helpful for those who use a lot of care

Use a lot of care and are willing to pay a high monthly premium so that nearly all other costs will be covered

Bronze
(Insurance Pays 60%
You Pay 40%)

Monthly Premium
$

Deductibles/
Out-of-Pocket Costs
$$$$

According to HealthCare.gov, this may be a good plan for people who…
Want a low-cost way to protect themselves from worst-case medical scenarios, with a low monthly premium, but higher costs for routine care

Silver
(Insurance Pays 70%
You Pay 30%)

Monthly Premium
$$

Deductibles/
Out-of-Pocket Costs
$$$

According to HealthCare.gov, this may be a good plan for people who…
Qualify for extra cost reductions, or those who are willing to pay a slightly higher monthly premium than a bronze plan to have more routine care covered

Gold
(Insurance Pays 80%
You Pay 20%)

Monthly Premium
$$$

Deductibles/
Out-of-Pocket Costs
$$

According to HealthCare.gov, this may be a good plan for people who…
Are willing to pay more each month to have more costs covered for medical treatment, particularly helpful for those who use a lot of care

Platinum
(Insurance Pays 90%
You Pay 10%)

Monthly Premium
$$$$

Deductibles/
Out-of-Pocket Costs
$

According to HealthCare.gov, this may be a good plan for people who…
Use a lot of care and are willing to pay a high monthly premium so that nearly all other costs will be covered

Additional Information

For a closer look at health insurance Marketplace plans, visit the “Employer-Sponsored and Individual Insurance” page (https://www.myhealthcarefinances.com/healthinsurance#EmployerandIndividualInsurance)

3 questions to ask when picking a health insurance plan

1. What will the plan actually cost me?
2. Are my doctors and other health care providers included in the plan’s network?
3. Does the plan cover my prescription drugs?

What Will the Plan Actually Cost Me?

Whether you are:

choosing between 2 or more plans offered by your employer
buying a plan sold in the state health insurance Marketplace
or want to compare your employer plan with a Marketplace plan

it is helpful to do the math to figure out the plan’s true costs and make an informed decision about which plan will work best for you.

Doing the Math to Compare Plan Options

Let’s say you have two plans offered by your employer and you’re trying to decide which one to choose:

Plan A

Plan Type

HMO

Monthly Premium

$25

Annual Deductible

$2,500

Co-insurance

70/30

Out-of-pocket-maximum

$7,000

Plan B

Plan Type

PPO

Monthly Premium

$100

Annual Deductible

$1,500

Co-insurance

80/20

Out-of-pocket-maximum

$4,000

At first glance, it may look like Plan A is less expensive due to its low monthly premium. Let’s do the math and find out!

Let’s calculate the total annual cost for each plan assuming you reach your out-of-pocket maximum for the year.

Plan A

Monthly Premium

$25 x 12 months = $300

Out-of-the-pocket-maximum

$7,000

Total Annual Cost

$7,300

Plan B

Monthly Premium

$100 x 12 months = $1,200

Out-of-the-pocket-maximum

$4,000

Total Annual Cost

$5,200

After doing the math, you can see that Plan B is actually the more affordable plan if your medical costs reach the out-of-pocket maximum during the year!

If you don’t expect to reach the out-of-pocket maximum, the math might look a little different! Let’s do the math assuming you will have $1,000 of medical costs during the year:

Plan A

Monthly Premium

$25 x 12 months = $300

Covered Out-of-Pocket Costs (Didn’t hit Annual Deductible, so bills were paid out-of-pocket)

$1,000

Total Annual Cost

$1,300

Plan B

Monthly Premium

$100 x 12 months = $1,200

Covered Out-of-Pocket Costs (Didn’t hit Annual Deductible, so bills were paid out-of-pocket)

$1,000

Total Annual Cost

$2,200

After doing the math, you can see that Plan A is the more affordable plan
in this specific example with lower medical costs!

It is important to remember that we don’t always know if or when we will have medical costs.

As a reminder, co-insurance typically applies after you hit your deductible, until you hit your out-of-pocket maximum. In this example, the medical costs are lower than the deductible for both plans A and B, so co-insurance will NOT apply while calculating covered out-of-pocket costs.

Covered Out-of-Pocket Costs
(Didn’t hit Annual Deductible, so bills were paid out-of-pocket)

Additional Information

For a closer look at the impact of co-insurance in a total medical cost calculations, visit the “Words that Matter for Health Insurance page” page (https://www.myhealthcarefinances.com/healthinsurance#WordsThatMatter)

What Does This Mean For You?

Let’s look at some more examples:

Jane

Jane is a 50-year-old woman, recently diagnosed with lung cancer. She is expecting to receive chemotherapy treatment this year and anticipates out-of-pocket medical costs more than $10,000.

Jane picks plan B.

Even though it has a higher premium, Jane does the math and sees if she reaches the out-of-pocket maximum of both plans, then Plan B will cost her less.

George

George is a 32-year-old man, who does not expect to use medical care in the upcoming year, other than his annual doctor visit.

George picks plan A.

George does the math not anticipating any large medical costs and sees if he does NOT reach either plan’s deductible, then Plan A will cost him less.

Additional Things to Consider When Picking a Plan

What will the plan actually cost me?

There are some other things to think about when looking at the cost of a plan:

Understanding Deductibles:

In addition to the total cost of a plan, you should also think about the impact your deductible amount will have. Some plans may have a high deductible, which means that you have to pay a lot of money up front, before your plan starts to pay their share of the cost.
Other plans may have a more expensive monthly premium, but have a lower deductible and lower out-of-pocket maximum, which spreads the amount you pay out-of-pocket throughout the year.

Are my doctors and other health care providers included in the plan’s network?

After you have looked at the cost of a plan, you should check if your doctors and other health care providers are in the plan’s network

In-network vs Out-of-network

Many plans will not cover medical care that you receive from an out-of-network provider.
Even if they do cover some of your medical costs for out-of-network providers - you may have to pay more out-of-pocket.

Plan Type

Your employer and state Marketplace may offer you multiple types of plans.
For example, you may have the choice between an HMO and a PPO. Typically, PPOs cost more than HMOs, but you have more choice and control with receiving medical care.
It may be helpful to consider the trade-off between flexibility and additional costs!

Does the plan cover my prescription drugs?

If you want prescription drug coverage, the final step is to make sure the plan you choose covers any prescription drugs that you are taking.

Check with the plan to see which drugs are covered by the plan.
If your plan does not cover prescription drugs you are taking or plan to take, you may end up paying more out-of-pocket to access your medications.

Additional Information

For more information about these topics, including worksheets to help you compare your own plan options – visit TriageHealth.org/HealthInsurance