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What do I look for when buying individual health insurance?

Keep in mind...
  • Health insurance must satisfy the Individual Mandate
  • Buying health insurance includes premiums and overall costs
  • Buying health insurance considers paperwork and steps users must perform
  • buying health insurance should consider medical needs and preferences
  • Buying health insurance should include how much it may be used

Buying health insurance is simpler than before the Affordable Care Act, but the choices are important for the best possible outcome for buyers. Insurers can no longer deny coverage. Obamacare ensures that the plans have a minimum value and essential health benefits.

Obamacare also provides free services that help prevent illness and detect conditions early for treatment. Comparison shopping is an excellent tool for finding the best match for individual health insurance.

Enter your zip code in our free search box to compare your state’s top insurance plans.

The Individual Mandate

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The Affordable Care Act requires that every citizen and legal resident get and keep qualified health insurance unless exempt. Those that fail or refuse to get coverage may face an individual shared responsibility payment.

The 2016 payment had a formula; it is the greater of 2.5 percent of annual income or the sum of $695.00 per individual adult.

The IRS applies the penalty on the basis of one-twelfth for each month of no insurance.

Qualified Health Plans

The Affordable Care Act requires plans to have a minimum dollar value and to provide the essential health benefits. Called qualified health plans, the Marketplace assures that every plan meets these standards. They must also be affordable. Individual health insurance plans are affordable if they require eight percent or less of the annual family income.

Costs of Health insurance

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The below-described costs are part of nearly every health insurance plan. They must be considered when estimating the costs of health insurance.

  • Premiums are the amounts paid for the insurance contract. There are many costs and charges beyond the premium based upon uses of medical services. Premiums run opposite of the other charges. High premiums usually get low deductibles, copays, and coinsurance. High premiums usually indicate generous levels of coverage
  • Deductibles are the amounts consumers must pay before the insurance company begins to pay its share of the costs. Low premiums usually get high deductibles. Once past the deductible amount, the insurance company must pay its part of the cost sharing. Cost sharing continues up to the out-of-pocket expense limit or deductible limit. After passing the limits, the insurance company must pay the entire costs of the covered, in-network, essential benefit.
  • Copays are small fixed charges that represent a small portion of the actual costs of a medical service. Copays help keep the services available and not fall into overuse. Low copays usually go with high premium policies. Copays may be limited in some plans to a certain number of uses. The copay can then go up, or the service may not be available for further use.
  • Coinsurance is the customer’s share of the insurance coverage amount for a benefit or service. It is usually expressed as a percentage.
  • Out-of-pocket limits for 2017 are $14,300 for family and $7,150 per individual
  • Deductible limits for 2017 are $14,300 for a family and $7,150 per individual adult.

Types of Obamacare Plans

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  • Platinum plans have high premiums and low deductibles. They offer low copays and coinsurance. These are ideal for cutting down on out-of-pocket costs and for moderate to heavy users of medical services. Once past the premiums, all other costs are on the low end of the scale. Platinum pays ninety percent of covered benefits and leaves ten percent for the consumer.
  • Gold plans have high premiums. Gold plans divide costs at eighty percent to twenty percent for the consumer. Excellent for moderate to heavy users of medical services, gold plans have high premiums but moderate deductibles, copays, and coinsurance.
  • Silver plans cover seventy percent of benefits with insurance and leave thirty percent for the consumer. Some high deductible silver plans work with Health Savings Accounts to provide funds for costs and a potential long term asset for the policyholder. Silver plans have moderately high premiums and high deductibles.
  • Bronze plans have the lowest premiums and high deductibles. They are ideal plans for those that do not need a lot of medical services beyond prevention services, wellness, standard check-ups, and health screenings.

Open Enrollment Period

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The open enrollment period is the best time to buy health insurance. The rule is that no one can buy insurance after open enrollment unless they fit into one of the below-listed categories for signup.

  • Special Enrollment Period due to changes called life events, one can get a sixty-day window to get new insurance
  • Extension of the open enrollment period permits persons to complete partial applications. States and the federal government announce them to compensate for factors that may have interfered with signups.
  • Exemptions are technically not signups, they are the statuses that do not have to signup. Exemptions can come from several sources including lack of affordable health plans

Networks

Networks are the important groupings of medical care providers in the plan’s system. Networks are also important because using them helps the consumer reach deductible and out-of-pocket limits. Once passed these milestones, the insurance company pays the entire costs of a covered benefit.

The network should have many acceptable services and providers It is important to minimize the use of outside resources when the customer must pay more, and they do not count against the policy limits.

The Types of Managed Care

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The type of managed care makes a difference in the ease of use. Some require paperwork or reimbursements, and some require referrals from a primary care doctor. The below-stated types are among the common forms of managed care.

  • HMO is the health maintenance organization. These plans emphasize prevention and use a primary care physician to oversee services to each user. The primary care physician makes referrals to network specialists when needed. The HMO does not cover outside resources.
  • PPO is the preferred provider organization. This form lets consumers decide when to go to network resources and when to go outside the network. The plan pays much less in cost sharing for outside resources than network resources. There is no primary care physician and no need for referrals.
  • EPO is the exclusive provider organization. Subscribers can use network resources with no referrals or primary care doctor. This type of plan does not use any outside resources. The costs savings and efficiency comes from complete reliance on network assets. Customers must pay their costs for outside specialist and providers.
  • HMOPOS is the point of sale option for the HMO. The primary care physician manages resources for each user and makes referrals to network specialists. The primary care physician can also make referrals to outside resources with insurance coverage. The cost sharing is much lower than when using network resources.
  • PFFS is the private fixed-fee-for-services form of managed health care. These networks often have lower prices and simple operations with little paperwork for users. Users are free to choose any medical care providers in the network. PFFS can pair with regional networks such as HMO or PPO to provide services to an employer-sponsored group plan.

Upper Incomes Must Search Outside

The Obamacare Marketplace provides premium subsidies and cost reduction assistance based on income. Those with incomes at or above 400 percent of the poverty line get little financial benefit from the marketplace. They should search outside to find plans that respond to their needs and preferences.

It is important to look at all of the options before making a selection. Plans outside of the Marketplace must meet the same standards for qualified health insurance.

Buying Health Insurance

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The main idea is health and well-being. Health insurance must get good medical care and at affordable prices. The premiums get initial attention as the monthly costs of the contract. Once one begins to use benefits, the deductible comes into play because it releases the insurance funds. One then seeks to have low copays and coinsurance so that the fees do not discourage needed healthcare.

Finally, once past deductibles and out-of-pocket limits, then the insurance company pays the entire costs for covered essential benefits. Comparison shopping can help find the best fit for individual needs and preferences.

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