Before you start looking at plans—whether it’s through your employer, the marketplace, or outside of the marketplace—it is essential to understand your entire family’s healthcare needs, and the medical and pharmacy services used most often. This includes making sure that everyone in your family, including the individual(s) with the bleeding disorder, has their needs met under the plan. Selecting the most appropriate plan can affects both your health and finances. This is a very personal decision. Only you know your and your family’s healthcare needs—use extreme caution when considering recommendations for how you should get coverage.
You will also need to have the right tools and resources readily available. NHF’s Personal Health Insurance Toolkit was designed to provide you with the information and resources you need to help make the selection process easier.
Some general questions to start thinking about are:
- What types of coverage are available to you? Who is eligible?
- Are you currently getting insurance through your or your partner’s employer?
- What are your out-of-pocket costs? Premiums? Co-pays and cost shares?
- What services and providers are covered?
Understanding the rules with your health plan and the range of covered services is critical. You should learn them before a crisis happens!
- You will need to find balance between what services are covered and where, with what you can afford
- Seek unbiased sources for help including a certified Marketplace navigator, HTC social worker, local chapter, NHF, and HFA
- They can help guide you where to look in your policy, what to look for, and how to compare plans. But remember only you can make the decision!
- Review your plan before open enrollment! Picking a policy is hard enough without the added stress of having to choose something on the spot.
- Plans are allowed to and will change. Do NOT assume just because you had the same insurer last year it’s the same plan this year. But, if changing insurers don’t assume anything about your policy. Always ask questions. If the person you are asking doesn’t know the answer, reach out. We can help figure it out together.
- Shop carefully! Look at all the details and don’t buy a plan just because it costs less.
- Ask questions such as: are my prescription drugs covered? Will I have access to the providers I need? Are there limits on services or drugs?
- Call your HTC social worker, chapter, and NHF for help in navigating plans! We can’t make the decision for you but can guide you.
- Don’t wait until the last minute to shop!
- Be prepared for higher premiums and plan accordingly.
Also known as exchanges, they are one stop shops for purchasing comprehensive health insurance. Each marketplace offers a variety of plan types including health maintenance organizations (HMO), preferred provider organizations (PPO), point of service (POS), among others. These plans are certified and provide all 10 essential health benefits (EHB’s) and all state mandated benefits. The costs vary widely based on plan type and place of residence. Qualified individuals may be able to obtain premium tax credits and cost-sharing reductions to make marketplace coverage more affordable.
Importantly, insurers cannot charge you more based on your medical history (have a pre-existing condition) or because you are a woman. Premiums can only vary age, the number of the people covered by the policy, and whether you use tobacco. In addition, plans must meet federal standards for network adequacy, ensuring access to primary care doctors, specialists, and “essential community providers” such as community health clinics and hemophilia treatment centers (HTCs).
Eligibility for Marketplace Coverage:
Consumers are eligible to purchase health insurance coverage through the marketplace if they:
- Live in the state in which they are applying;
- Are a U.S. citizen (or are lawfully present); and
- Are not currently incarcerated.
Consumers will need to go through additional eligibility screening to determine whether they are eligible for premium tax credits or cost-sharing reductions to help make their marketplace plan more affordable.
When can I enroll in private coverage through the marketplace?
In general, you can only enroll in coverage during the specified open enrollment period. Marketplace open enrollment for states that do not operate their own marketplace (using healthcare.gov) begins November 1 and goes through December 15. If you plan to sign up for a plan through the marketplace, be sure to complete your application and select your plan before the deadline. If you miss the deadline, you must wait till the next open enrollment period.
However, if you experience certain changes in circumstances during the year, meaning have a qualified life event (i.e., birth, marriage, divorce, lost job-based insurance, etc.), you may qualify for a special enrollment period (SEP). If you qualify you must enroll within 60 days. This is a firm deadline.
It is important to note that loosing coverage because you didn’t pay your premiums or voluntarily dropped your coverage, does not qualify you for an SEP. You must meet the specific criteria used by the marketplace to qualify.
If you are buying non-group coverage for yourself and/or your family outside of the marketplace, you still can only enroll in coverage during the open enrollment period, provided you do not qualify for a special enrollment period.
Types of Plans and Standardized Tiers
Plans sold both on and off the marketplace are standardized and come in four metal tiers: bronze, silver, gold, and platinum. The lowest level of coverage (60 %) is called the bronze level. A silver level plan will cover 70% of total average costs for covered benefits, a gold plan covers 80 %, and a platinum plan covers 90%.
Buyer Beware—Expansion of Non-ACA Compliant Plans
Types of non-compliant plans
- Short-term, limited duration (STLD)
- Limited benefits and financial protection
- Exclude coverage for basic services (i.e., no prescription drug coverage)
- Can discriminate individuals with pre-existing conditions
- Can rescind, leaving consumers uninsured and with large bills
An individual health insurance policy is one that is not provided through an employer and covers a single person or multiple people (families, mother and dependent children, husband and wife, etc.). These policies are regulated under state and federal law and can be purchased either inside or outside the marketplace.
Shopping for coverage outside the marketplace
Consumers can also buy health coverage outside the marketplace. For the most part, insurers selling coverage outside the marketplace will likely provide many of the same consumer protections that insurers inside the marketplace provide.
However, some types of coverage sold outside the marketplace are exempt from the new rules, and consumers should fully review the terms of their coverage to ensure it provides adequate protection. For example, some plans sold outside the marketplace may still discriminate based on health status, won’t provide essential health benefits, and may not meet the federal limit on out-of-pocket costs. In addition, not all coverage sold outside the marketplace meets the federal standard for “minimum essential coverage.”
Financial assistance (subsidies and tax credits) can only be obtained with marketplace plans. In addition, some special enrollment periods (SEP) for enrolling in or changing plans outside the open enrollment period are only available to Marketplace plan enrollees.
However, plans sold outside the marketplace that comply with the ACA’s consumer protections may be a better option for some consumers, particularly if a preferred provider is not part of any marketplace plan network and/or the consumer is ineligible for financial assistance and doesn’t expect a mid-year drop in income (which, if enrolled in the marketplace, would qualify them for a SEP to enroll in coverage with financial help).
Employer sponsored insurance, often referred to as a job-based plan or group health plan, is health insurance provided by an employer for their employees and in some cases, their families. Typically, the employer covers a portion of the premium costs, and plan options may include HMOs, PPOs, and EPOs, among others.
However, if you want to explore other options that may be available to you, such as Medicaid or a plan through the Marketplace and see how they compare to your employer plan, you can. However, there are some important things to consider before making a decision to reject your group health plan. Employers typically pay a portion of the premiums associated with a job-based group plan. If you choose to obtain a marketplace plan, the employer does not contribute to your premiums.
An employer-sponsored plan is considered “affordable” if the employee’s share of the lowest cost self-only coverage that meets the minimum value standards is less than 9.5 % of the family’s income. It’s important to remember that affordability is determined only by the amount you pay for self-only coverage from your employer. If you pay more than 9.5% of your income for family coverage, the plan may still be considered affordable.
Job-based health plans can be either fully insured or self-insured. It is important to understand the difference because self-insured plans are not required to comply with all provisions of the ACA.
Copyright National Hemophilia Foundation
Last Updated June 2023