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Health Insurance Marketplace 101: Things to Know Before You Buy

By Edited Nov 13, 2013 2 1
Health Insurance Marketplace
Credit: www.stockmonkeys.com

As an integral part of the Affordable Care Act (aka Obamacare), health insurance marketplaces will be launching soon. Using the Marketplace simplifies the process of finding health insurance for you and your family by being able to compare all of your options in one place. Once you have completed the application you will be able to view all the private health plans available to you so you can find a plan that fits your needs and budget. By using the Marketplace you can also find out if you qualify for lower costs.  Additionally, you can learn if you are eligible for Medicaid or if your children are eligible for the Children's Health Insurance Program (CHIP).

Before getting started check with your employer to see what options they plan to offer you in 2014. Next, gather your household income information such as a few current pay stubs and your most recent tax return. You should also have a budget prepared so you know how much you can afford before selecting a plan.

Important Dates: Mark Your Calendars

Open enrollment begins October 1, 2013. This is the first date you can apply for coverage through the Marketplace.
Please note, however, that if you or your family qualifies for Medicaid or the Children's Health Insurance Program (CHIP), you can apply at any time. You do not have to wait for open enrollment in the Marketplace.

Your coverage effective date will depend on when you enroll and pay your first premium payment during the open enrollment period.

Enrollments between October 1, 2013 and December 15, 2013 with first premium payment: Effective date will be January 1, 2014.

Enrollments between December 16 and March 31, 2014 with first premium payment is as follows:
Between the 1st and 15th of the month: Effective date will be the first day of the next month.
Between the 16th and the last day of the month: Effective date will be the first day of the second following month.

You should also mark March 31, 2014 on your calendar. This is the date open enrollment for 2014 ends. After this date you can only enroll if you have a qualifying event. Examples of a qualifying events are: losing coverage due to job loss or divorce, or adding coverage due to the birth of a child.

Understanding Networks

Most insurance plans use a network of providers. A network is comprised of hospitals, doctors, and other providers or facilities to provide coverage to it's members at a lower cost.

Health Maintenance Organizations (HMO's) generally limit coverage to providers in their network. If you choose a provider outside of the network, you may be responsible for paying the full cost of the services rendered to you. With most HMO's you have to select a primary care provider. If you need to see a specialist, you will need to go to your primary care provider first and obtain a referral to see the specialist. If you do not obtain the referral, you may have to pay the full cost of the services rendered by the specialist.

Preferred Provider Organizations (PPO's) allow you to use providers in or outside of their network. If you use an out of network provider, you will have to pay more than if you had stayed within the network, but services rendered will not be denied completely. When considering PPO plans be sure to look at the coverage and what you could be responsible for if you stay in network or go out of network. Unlike HMO's, PPO's do not require referrals to see a specialist.

Coverage Terms

Copayment (Copay)

A Copayment is a flat rate you will pay for certain in network covered services. For example, a copayment usually applies to a doctor's office visit and is paid up front when services are rendered (unless your doctor allows you to pay it later). Unless your coverage plan specifies otherwise, copayments do not apply towards meeting your deductible or out of pocket maximum.

Deductibles, Coinsurance, and Out of Pocket Maximums

When comparing coverage levels, you will see a break down of the deductible, coinsurance, and out of pocket maximum.

Fees Deductibles Copayments Coinsurance

$200 Deductible
20% Coinsurance
$1000 Out of Pocket Maximum

The Deductible is the amount you will have to pay per policy period for services rendered before your insurance begins to pay for your services.

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The Coinsurance is the percentage of services rendered you will pay after you have met your deductible. The remaining percentage will be paid by your health insurance plan. The percentage you pay applies towards meeting your Out of Pocket Maximum.

The Out of Pocket Maximum is the maximum amount you will pay during your policy period. The policy period usually starts over every January 1st. This means that on January 1st you will have to meet your deductible again before coinsurance picks up and starts accumulating towards meeting your out of pocket max.

It should be noted that items such as payments of non covered services and premium payments for your health plan are not included towards meeting your deductible or out of pocket max. Additionally, if you selected a PPO, you will likely have separate deductibles, coinsurance, and out of pocket max amounts for in network and out of network services.

Coverage Riders

Riders are types of coverage that are optional to your health insurance. For example, dental and vision are usually covered as riders. Benefits for these services are usually not covered under your health plan, however, you can have them added to your plan or get coverage under a stand alone provider. Be sure to read the details so you can make sure you have all the coverage you need.


If it is determined that you can afford insurance and choose to not get it, you could be looking at penalty fees. While the fee will start at 1% of your yearly income or $95 per person for the year, whichever is higher, the fees will increase. By 2016 the fee will be 2.5% or $695 per person, whichever is higher. There are also penalty fees for uninsured children.

For details on what is or is not considered minimum required coverage and other eligibility factors that could determine if you are subject to the penalty fee, please contact your state department of insurance.

Additional Details and Resources

Navigating the details of the Affordable Care Act can be confusing and while I have worked in the insurance industry for 4 years, I am not an expert on these new guidelines. The subjects discussed here are meant to be informative and are bits of knowledge I discovered in researching the Marketplace for myself. Please refer to your state department of insurance for questions, details and additional resources. I highly recommend contacting them to be sure you fully understand all that is involved with the Affordable Care Act and how it applies directly to you.

Fees Deductibles Copayments Coinsurance
Credit: www.stockmonkeys.com


Sep 12, 2013 11:19pm
Thank you for the detailed explanations. Thumbs up for your article!
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