Under the Affordable Care Act (ACA, or Obamacare), most non-grandfathered individual and small-group major medical insurance plans are required to cover essential health benefits — including mental health, substance use disorder, pediatric services, prenatal and newborn care and habilitative and rehabilitative devices and services. However, specific coverage varies by state and plan type. For example, some plans may offer telehealth services or 24/7 nurse lines while others might focus on chronic conditions like heart disease or diabetes and provide education or support groups to help manage the condition.
When selecting a plan, it’s important to understand the differences between deductibles, copayments and out-of-pocket maximums. It’s also vital to check for coverage of prescription drugs and if the plan offers any extra benefits, such as a discount on weight loss programs or a free annual wellness visit. A health care agent or broker can help you compare plans and options. And remember that the plan you select must be renewed each year during open enrollment or a special enrollment period triggered by a qualifying event.
Choosing a plan type
If you’re looking for affordability, consider a Bronze plan. Bronze plans have lower deductibles and copayments than Silver plans. If you’re not eligible for a subsidy, it might make more sense to select a Silver or Gold plan that has higher premiums but lower out-of-pocket maximums.
Another consideration is whether the plan you choose has a preferred provider network. These networks are comprised of doctors and hospitals that have contracted with the insurance company to offer services at a set price, or capitation, which is typically less than the providers’ regular charges. You’ll pay more out-of-pocket costs if you see a provider outside the network.
You can find provider networks for plans offered in the Marketplace by using the federal government’s Find Local Help tool to schedule in-person or phone appointments with local, certified assistance brokers and agents. You can also search for a doctor or facility online to see if they accept the plan you are considering.
Your location is a bigger factor in your insurance costs than you might think. That’s because the health of your neighbors determines how much insurers charge for policies in your area. So if you live in a state with healthy residents, your rates will be low. On the other hand, if you live in a state with unhealthy residents, your rates could be significantly higher.
Other factors that can affect your premium include your age, family size, tobacco use and your body mass index (BMI). In general, older people pay more for their coverage than younger people. Also, a family plan with one spouse and children will cost more than a single-person plan. And if you are obese, your insurer might increase your premiums because of the greater risk that you will need costly medical care in the future. The good news is that the ACA prohibits insurers from denying coverage to applicants with preexisting medical conditions, and it limits how much your health insurance company can raise your premium each year.