Navigator Guide FAQ of the Week: Comparing Plans

With Open Enrollment now underway, consumers are weighing their options for 2021 and trying to find the right plan that meets their health needs. As consumers make their decision, it is important for them to understand what they are buying and what coverage their plan provides. This week the CHIR team answers questions about the various plans offered through the marketplace.

What health plans are offered through the marketplace?

All health plans offered through the marketplace must meet the requirements of “qualified health plans.” This means they will cover essential health benefits, limit the amount of cost-sharing (such as deductibles and co-pays) for covered benefits and satisfy all other consumer protections required under the Affordable Care Act.

Health plans may vary somewhat in the benefits they cover. Health plans also will vary based on the level of cost-sharing required. Plans will be labeled bronze, silver, gold, and platinum to indicate the overall amount of cost-sharing they require. Bronze plans will have the highest deductibles and other cost-sharing, while platinum plans will have the lowest. Health plans will also vary based on the networks of hospitals and other health care providers they offer. Some plans will require you to get all non-emergency care in-network, while others will provide some coverage when you receive out-of-network care.

Insurers in some state-run marketplaces may offer standardized plans. Standardized plans at each metal level will have standardized benefits with the same fixed deductible, out-of-pocket costs, and cost-sharing amounts. The purpose of these plans is to simplify the consumer shopping experience since consumers will know that certain features like the deductible and cost-sharing amounts under such plans will be the same within a metal tier. Standardized plans also cover some important services before the deductible, such as primary care, generic drugs, and some specialty services.

Will covered benefits under all marketplace plans be the same? How can I compare?

In general, marketplace health plans are required to cover the 10 categories of essential health benefits. However, insurers in many states will have flexibility to modify coverage for some of the specific services within each category. Any modifications must be approved by the marketplace before plans can be offered. Also, your cost-sharing for various services is likely to vary from plan to plan. All health insurance marketplace health plans must provide consumers with a Summary of Benefits and Coverage (SBC). This is a brief, understandable description of what a plan covers and how it works. The SBC will also be posted for each plan on the marketplace website. The SBC will make it easier for you to compare differences in health plan benefits and cost-sharing.

Plans may differ in other ways, too. For example, the network of health providers might be different from plan to plan.

In some states, insurers may be required to offer standardized plans. For these plans, the covered benefits will have the same fixed deductible, out-of-pocket costs and cost-sharing amounts for certain services. In particular, certain services, such as primary care, generic drugs, and some specialty care services may be covered without you needing to meet your deductible.

What is the difference between a premium and a deductible? If I want to save the most money possible, should I just pick a plan with the lowest premium?

A premium is the amount you pay for your health insurance every month. A deductible is the amount you pay for covered health care services before your health insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.

Before enrolling in a plan, you should check its provider network for your preferred doctors or facilities, and check the formulary for your medications. Often, if you receive services from an out-of-network provider, those charges will not be counted towards your deductible.

You should also consider how often you use health care services and how much you would be able to pay out of pocket amidst an expensive unexpected emergency. It is important to find a reasonable balance between an affordable premium and also a deductible that would be manageable to pay out of pocket throughout the year or all at once in the instance of an unexpected medical event. A plan with the lowest premium may not necessarily be the most financially beneficial plan to choose if you have a medical condition that requires prescription drugs or visits with your provider throughout the year.

Open Enrollment runs through December 15 in most states. Look out for more weekly FAQs from our new and improved Navigator Guide, or browse hundreds of questions and answers here.

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The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.