Some useful things to know about the Health Insurance Marketplace


Jonathan ColonI’m sure that by now, you’ve heard a plethora of the Health Insurance Marketplace opinions (from really good to really bad) and you stopped tuning in to the daily updates on what’s happening with the Affordable Care Act, but as we quickly approach and pass the March 31st open enrollment date, I thought it would be both useful and helpful to share an impartial summary on some of the most important aspects of the Marketplace.

First of all, let’s talk about the somewhat confusing health plan categories (a.k.a. metal levels). The Marketplace is separated into four main levels of coverage: Bronze, Silver, Gold, and Platinum levels. These were created to categorize health and financial needs of the population, as well as to identify the share that each level or plan contributes towards healthcare services. They also indicate the percentage that those covered by the plan will pay towards care they receive. These are in the form of deductibles, co-payments, and co-insurance costs. Below you can see a summary chart of the plans’ average percentage splits by metal level.

Level Plan’s %
Bronze 60%
Silver 70%
Gold 80%
Platinum 90%

Please note these are averages and the chart does not include premium costs, which as expected, work inversely to the amount a patient would be responsible for the care they receive (i.e. the less money spent on a premium, the higher your share will be for healthcare services received, or for those of you who like to see things from a glass-full perspective, the more money spent in premiums-the more coverage your plan will offer for services received). A word of advice would be to objectively take an inventory of the number of physicians’ visits you’ve had in the past year or two as well as the medications currently take. If you know these will be frequent and are taking multiple medications, you may want to consider a Gold or Platinum plan. Before selecting a plan, you can also compare plans in your state and select the one that best fits your needs.

A very important aspect of the Insurance Marketplace is that as of January 1st, you can’t be denied coverage for pre-existing conditions, and all associated plans must cover essential health services, with co-payments and co-insurance dollars adding towards your deductible. Services such as preventive and wellness services, mental health services, emergency services, hospitalizations, and occupational and physical therapy are included, giving millions of previously uninsured individuals the opportunity to access these very important services.

Also, consider looking at available federal subsidies that may assist you in lowering both premium and care costs. Options include cost-sharing reductions that lower your out-of-pocket costs for care received, as well as advanced premium tax credits designed to control the amount paid each month in premiums. It is important to note that these subsidies are available to persons ineligible for Medicaid and Medicare coverage and for those unable to get covered through their employer, and they do vary by state. The Kaiser Family Foundation has a very useful subsidy calculator that can help you determine whether you are eligible for one of these subsidies.

Lastly, please now that Monday, March 31st is the last day of open enrollment and you will not be able to get Marketplace coverage until the next enrollment period begins—unless there is a qualifying event such as marriage, divorce, or giving birth. So if you think the Marketplace exchange may be an option for you or if you are uninsured, visit www.healthcare.gov and see if there is a plan that fits your needs and budget.