Low-cost adult health insurance plans through the Exchanges save a substantial amount of money. But surprisingly, these policies also contain quality benefits you may not expect from a “cheap” policy. Many state-mandated and preventive benefits must be included, along with 10 “essential health benefits” that are a federal requirement since the ACA legislation was passed. Future Administration changes will provide additional affordable options, with increased flexibility when choosing benefits. Individual states will also have a larger role in determining plan availability.
The Marketplace also offers numerous affordable choices that are popular with individuals, families, the self employed and persons without medical benefits. If you are retired and not yet eligible for Medicare, you should consider these types of plans, depending on medications and pre-existing conditions (if any) you currently have. We make it easy for you to enroll in the cheapest contracts, so you can quickly apply online or direct, and get covered! Prior lapses in coverage may result in waiting periods for pre-existing conditions, depending upon the type of plan.
NOTE: Seniors (applicants that qualify for Medicare) are not able to enroll in Marketplace coverage. However, their spouse or dependents may be eligible for a policy, along with a federal subsidy, depending on the household income. The Senior’s income, however, must be considered in the subsidy calculation. Medigap (Supplement and Advantage) plans are offered to persons that have reached age 65 and enrolled in Medicare Parts A and B. It is possible that one spouse may qualify for Medicare and supplemental coverage, while the other spouse qualifies for a private plan and additional federal financial assistance.
Senior plan benefits vary greatly from Under age-65 benefits since many items are fully are partially covered by Medicare. The Open Enrollment period for under-65 and over-65 applicants is also different. Typically, Medicare Open Enrollment ends December 7th, and Marketplace Exchange Open Enrollment ends January 15th. However, several State-sponsored Marketplaces offer extended Open Enrollment periods. Also, during health pandemics, the federal government may declare a special OE period.
Plan Availability For Adults
We find the best plans that are available from the “name” and smaller carriers in your area, and quotes are “real time” and based on the information you provide. There are never any obligations associated with using our website. You can also ask about supplemental plans, which sometimes should be considered if you already have purchased a plan through your employer or you have secured private benefits. Ancillary contracts have become very popular, as specialized disease coverage (cancer and heart disease) has helped saved consumers millions of dollars in medical expenses. Dental, vision, and international coverage is also offered.
For example, if you select a Bronze tier policy that offers a low premium, you probably will have to accept a deductible of $5,000-$9,100. The total family deductible and coinsurance maximum could reach $18,200. Although you can purchase a Silver or Gold tier plan that will lower copays and deductibles (especially if your income is below 250% of the Federal Poverty Level), you may ultimately pay thousands of dollars more each year in premiums.
In some situations (not all), owning a supplemental plan option (off-Exchange) with a higher-deductible plan will be more cost-effective than having a lower-deductible contract. For example, the Bronze policy option may cost $3,000 (per year) less. The supplemental contract may cost $1,500 and cover most potential out-of-pocket costs. However, purchasing a secondary policy is often not cost-effective, when exclusions and waiting periods are considered. Also, as you get older, and your household income possibly changes, it’s imperative to review all options before enrolling for the next calendar year. When eligible, Medicare options will be quite different than under-65 options.
NOTE: It’s important to consider this concept on an individual basis. In many situations, because of health conditions, policy provision, or other factors, an upper-tier plan, although more expensive, is the best option. Availability of facilities should also be considered. For example, many plans may not consider highly-rated hospitals (Cleveland Clinic, Johns Hopkins Hospital, UCLA Medical Center, Northwestern Memorial Hospital, and Mayo Clinic) as “in-network” facilities.
An HMO plan will also have more restrictive network provisions than a PPO plan, including limited or no out-of-network coverage. EPO plans have become increasingly popular for carriers offering Marketplace plans.
Deductibles on policies are usually between $0 and $9,100 ($18,200 per family) although you can find options as low as $500 and as high as $20,000 on several supplemental contracts. We work with you to find that perfect “sweet spot” that optimizes your cost. Depending on your adjusted gross income (AGI), you also may be eligible for tax help from the government that could make a huge difference in what you pay. The “maximum out-of-pocket expense” must also be considered to properly compare policies.
For example, a family of four residing in Atlanta (oldest adult age 45) with a household income of $70,000 would receive a credit of approximately $15,000! If the income is increased to $90,000, the credit is $12,000. And if you are “fortunate” enough to make a $200,000, a subsidy is still offered. This is one reason why many higher-income consumers are now supporters of “The Affordable Care Act.” Although future legislation (if passed) is likely to further increase subsidies for applicants over the age of 50, it’s possible that lower-income households may pay higher premiums.
What Is A “Catastrophic” Policy?
Typically, a catastrophic policy has a high deductible (more than $5,000) and you are required to pay all medical expenses out-of-pocket until the deductible is met. Although approved and mandated preventive benefits are covered (at 100%), more common claims, such as office visits for colds and the flu, along with prescriptions, still must meet the deductible. Also, inpatient and outpatient surgeries and procedures are subject to the policy deductible, along with many common diagnostic tests and x-rays.
Some plans may offer a limited number of office visits (primary care physician) subject to a copay of about $30-$50, but many others do not. There also may be a coinsurance to meet, depending on the size of the deductible. Although visits to a specialist are covered, a copay may not be offered. If available, the copay may be quite high ($75-$150).
Skilled nursing care, home care and hospice care are often covered benefits subject to policy limitations. Chemotherapy, radiation, organ transplant drugs, Cat Scans, and MRIs are generally covered as well. Some of the most common healthcare expenses that are not covered include primary physician and specialist visits, weight loss and cosmetic surgery, and several outpatient expenses and child immunizations.
Typically, three office visits to a primary care physician are included in the benefits. A copay of about $35 is common, although $0 copay are also offered by many carriers. It is important to understand that a deductible (different than a copay) is often placed on specialist and Urgent-Care visits. However, as earlier mentioned, preventive visits are not subject to deductibles, copays or coinsurance. An annual routine physical with no complications should result in no out-of-pocket expense.
Who Can Buy It?
Not everyone is eligible to purchase a “catastrophic tier” policy. Under Obamacare guidelines, the requirement is that applicants must be under the age of 30. For persons over the age of 30, the only way to qualify for this type of policy is through a “hardship exemption.” There are 14 “hardship exemptions,” and some of the most common are found in this link. Common examples are if applicants are homeless, facing eviction or foreclosure, victims of domestic violence, received shut-off notice for gas or electric, filing for bankruptcy, and have outstanding medical expenses that can not be paid.
Since a federal subsidy is NOT available with this type of policy, often a “Bronze” contract is less expensive and offers richer benefits. Also, “Silver” tier policies feature cost-sharing, (deductibles can reduce, depending on Federal Poverty Level), and lower-income persons, including students may find these options to be a better fit for their situation. Households that require the most comprehensive and richest benefits, regardless of cost, can choose low-deductible Platinum or Gold plans.
Christian health insurance co-op reviews are also offered by our research staff. It is imperative to understand that these policies are not considered “Exchange” contracts and subsidies are not offered. Also, there are only a handful of companies that have the experience and necessary financial stability (for now!) that warrants their consideration. We closely examined the three largest carriers, which are Medi-Share, Samaritan Ministries, and Christian Healthcare Ministries. Although their plans warrant consideration, there remains uncertainty if these types of options are dependable long-term solutions.
Maternity And Other Required Benefits
Maternity benefits were previously offered by selected carriers, subject to waiting periods of 9-12 months. Complications of delivery were sometimes covered without adding an additional rider. In the years immediately preceding 2014, maternity benefits became harder to secure. However, selected hospitals did offer maternity packages. Although this benefit was not considered insurance, price and coverage were competitive.
However, beginning with Exchange plans under the first Open Enrollment in 2014, maternity benefits were automatically covered, since they were considered one of 10 “essential health benefits.” Thus, they had to be automatically included on subsidized and unsubsidized plans. And that has not changed. Although you may still incur high out-of-pocket expenses, options are available that feature lower deductibles and out-of-pocket expenses less than $3,000.
Preventive benefits are included on high-deductible plans and are covered at 100% and not subject to additional out of pocket costs. Some of these benefits include mammograms, pap tests, OBGYN visits, annual routine physicals and child preventive services. Also, no coinsurance or waiting period is applicable.
Note: Non-preventive services may be treated differently and subject to a higher payment. But on many plans, if the deductible is reached, there may be very little or no more cash outlay required for covered treatment. Thus, when scheduling a major surgery with a cost that exceeds your policy deductible, a January or February surgery date can be very cost effective.
Should I Buy A Catastrophic or Bronze-Tier Policy?
The typical person that purchases these types of policies policy is usually dependent-free and between the ages of 21 and 35 or 50 and 64 (with exceptions, of course). Many purchasers are self-employed and do not qualify for group coverage. They tend to be healthy, with no serious health concerns and willing to pay a lower premium in exchange for a higher deductible. With most plans, after the deductible is met, a coinsurance of 0%-30% is usually required up to a specified limit. But once that limit has been met, there is no cap on the covered expenses that the insurer ultimately pays.
Depending on the state, only “short-term” (and limited benefit) plans are underwritten and subject to review. Although a physical is rarely required, medical questions must be answered and occasionally the insurer will order records to provide details about a specific condition on temporary contracts. Most existing conditions will not cause a denial in coverage, However, certain conditions, such as AIDS, heart disease, BMI above 45 and Multiple Sclerosis will likely result in a declination of coverage.
Legislation changes six years ago also forced the maximum coverage period to be reduced to three months in several states. However, renewals (subject to medical underwriting) are typically offered. Most states allow 12-36 months of temporary coverage.