Health Insurance Marketplace: What to Know and How to Choose
Editor's note: With the election of Donald Trump, who pledged to "repeal and replace" the Affordable Care Act, we are likely to see big changes in the ways people access health insurance. The road forward is uncertain, but experts have told LBBC that marketplace plans are unlikely to go away in 2017 if people purchase plans and pay their premiums. We'll report on this ongoing story in the coming months at LBBC.ORG.
Elaine Davis, 62, of Newton, Kansas, was diagnosed with stage IIa breast cancer in October 2015 — just 5 months after retiring from her job. She and her husband decided they would get their 2016 health insurance from one of the marketplaces created by the Patient Protection and Affordable Care Act, also called Obamacare. These marketplaces serve people who don’t already have private insurance — through an employer, for example — and don’t qualify for Medicare or Medicaid.
Every year there is an open enrollment period, during which you can sign up for health insurance through your state’s marketplace, or the federal marketplace at HealthCare.gov, depending on where you live. The open enrollment period to sign up for a 2017 plan began November 1 and runs through January 31.
Updates for 2017Premiums, the monthly price you pay the insurance company in order to have insurance, rose significantly for 2017: Premiums for mid-level plans increased by an average of more than 20 percent. People using the marketplace are, overall, sicker than expected, and many younger, healthier people aren’t buying plans or are buying the cheapest plans. This caused insurance companies to lose money, and in turn, raise prices or stop offering plans in certain areas. Aetna offered plans in 15 states in 2016, but offers them in just four (Delaware, Iowa, Nebraska and Virginia) for 2017. UnitedHealthcare offered plans in 34 states in 2016, but offers them in just three (Nevada, New York and Virginia) for 2017. Humana left most states in which it offered marketplace plans. And Blue Cross Blue Shield offers fewer plans in some places than it did for 2016. Fewer companies lead to higher costs and fewer healthcare providers to choose from.
Kelly Nemecek, 50, lives in Phoenix, Arizona, where there is only one marketplace insurer for 2017. She was diagnosed with stage IIIa breast cancer in April 2015. She’s gotten health insurance through the marketplace since 2012, when it was first available, and is now on her fourth or fifth plan. Kelly’s premiums have more than doubled in that time span. Since UnitedHealthcare left her marketplace, Kelly had to pick a new plan for 2017.
STILL THE SAME
The core principals of the Affordable Care Act haven’t changed: The law requires plans to cover cancer screening, treatment and follow- up care. It also stops insurers from denying coverage because of a pre-existing condition, including cancer, or charging a person more just because they’re sick. It stops insurers from putting a dollar limit on how much care they’ll pay for and it sets a limit on total out-of-pocket costs you have to pay. In 2017, that limit is $7,150 for individual coverage and $14,300 for family coverage (not including monthly premiums). You may buy a plan that sets the limits you pay out of pocket lower than this, but as that limit goes down, your premiums go up.
Choosing the Right Plan for You
Marketplace plans come in platinum, gold, silver and bronze, as well as “catastrophic.” (Catastrophic plans are only available to people who are under 30 or who qualify for a hardship exemption, and they have very high out-of-pocket costs.)
Platinum plans tend to have:
- High premiums
- More providers
- Low deductibles, the amount of money you have to pay out-of-pocket each year before insurance starts paying your medical bills
- Low copays, costs you’re responsible for when you visit a doctor or fill a prescription
- Low co-insurance, the percentage of the cost of a service that you’re responsible for
- Low out-of-pocket maximums, the most you will have to pay out of pocket for covered medical expenses
Bronze plans tend to have:
- Low premiums
- Fewer providers
- High deductibles
- High copays
- High co-insurance
- High out-of-pocket maximums
Gold and silver plans fall in the middle. When choosing a plan, consider its prescription coverage, providers and cost. Make a list of the prescriptions you take and check that each plan you’re considering covers those medicines. Check what your prescription copays will cost and look for different ways to get your medicine, such as mail-in options or specialty pharmacies.
Every plan has a network of healthcare providers. Check if your preferred providers are in-network in the plans available to you, because if you visit a provider outside that network, your plan may cover less, or none, of that provider’s fee.
Premiums are the most obvious thing to consider when looking at the cost of a plan, since you must pay the premium every month, whether or not you have any medical expenses. But deductibles, copays and co-insurance are also important because when these are higher, using your insurance costs you more.
You can’t predict all the medical care you will need and what it will cost. But you can make a list of expected medical expenses and compare each plan’s coverage. This can give you a sense of how different premiums, deductibles, copays and co-insurance will affect your healthcare costs.
Find Help Understanding Plans
Joanna L. Fawzy Morales, Esq is a cancer rights attorney, author, speaker, and CEO of Triage Cancer, a national nonprofit connecting people to cancer survivorship resources. Triage Cancer teaches people to minimize their out-of-pocket costs. They often find that a plan with higher premiums but lower out-of-pocket costs, including low out-of-pocket maximums, can save clients thousands of dollars a year. This may be especially true for people with metastatic disease, whose treatment is ongoing. Visit triagecancer.org for information that can help you better understand your health insurance options. Other nonprofits, such as the Patient Advocate Foundation, may also be able to help.
Navigators are another helpful resource. These are people in each state who are trained to help you use the health insurance marketplace. Visit localhelp.healthcare.gov to find one near you.
Financial aid includes premium tax credits and cost-sharing reductions. These forms of assistance are only available through the marketplace.
A premium tax credit can lower your monthly premiums by hundreds of dollars. Or, you can pay the full premiums and get a refund when you file your taxes. Most people are eligible for a premium tax credit, and when premiums increase, so do the value of these tax credits and the number of people who are eligible for them. Facing limited options, Kelly picked a silver plan for 2017 that, even with a $178 subsidy, will cost $100 more per month in premiums than her 2016 plan.
Cost-sharing reductions can give you lower out-of-pocket maximums, deductibles and copays than people who have the same plan but don’t qualify for this form of aid. This is only available to people who choose a plan in the silver category.
How much financial help you get depends on your household income and how many people live with you. If your state participates in the federal healthcare marketplace and you have a 2-person household, you qualify for:
- a premium tax credit if your household income is between $39,826 and $63,720
- a premium tax credit and cost-sharing reductions if your income is between $16,020 and $39,825
- If your income is above $63,720, you don’t qualify for these forms of financial aid. If your income is below $16,020, you may qualify for Medicaid, a government healthcare program for low-income people.
If your state participates in the federal healthcare marketplace and you have a 4-person household, you qualify for:
- a premium tax credit if your total income is between $60,626 and $97,000.
- a premium tax credit and cost-sharing reductions if your income is between $33,534 and $60,625
- If your income is above $97,000, you don’t qualify for these forms of financial aid. If your income is below $33,534, you may qualify for Medicaid.
Visit healthcare.gov/lower-costs for more examples. If your state has its own marketplace, look at its website, which can be found at healthcare.gov/marketplace-in-your-state, to learn if you qualify for subsidies.
If your income is too high to qualify for financial aid from the government, you can still buy a plan through the marketplace at full price. Or you can buy a plan directly from an insurance company. HealthCare.gov’s Plan Finder tool can help you find a plan outside the marketplace.
Elaine chose a Blue Cross Blue Shield silver plan for 2016, but went with a gold plan from that same company for 2017. Her premium will be higher, but she will also receive a bigger government subsidy, making the price she pays for the premium lower. She’s frustrated that her plan doesn’t cover any out-of-state providers, but she’s grateful for the peace of mind her insurance provides.
“If we [hadn’t] had that option, I think we would have spent somewhere close to a quarter of a million dollars on treatment so far,” she says, “and that would have definitely bankrupted us.”