There are a lot of things to know about Marketplace Healthcare or Obamacare. After being on it a year, doing significant research, and talking to many people who are on it I share some tips, secrets (things I really wished I had known about Obamacare before choosing a plan in the marketplace), and overall general information. I hope that the information provided helps you and your family.
Most of you know that on March 23, 2010 President Obama signed into law the Patient Protection and Affordable Healthcare Act… commonly known as Affordable Healthcare Act, Obamacare, or the Marketplace.
General information about Healthcare through the Government Marketplace.
- Since signing the Affordable Healthcare Act, everyone qualifies for health insurance and cannot be denied healthcare based on any pre-existing conditions.
- Everyone is now REQUIRED to have healthcare. This is known as the individual mandate. Most individuals over 18 are required to have it or pay a tax penalty.
- At first the penalty to pay wasn’t all that steep but it goes up over the years. For example: In 2015, the penalty is $325.00 per adult and $162.50 per child (up to $975 for a family) or 2 percent of annual income, whichever is greater. By 2016, the penalty is $695 per adult and $347.50 per child (up to $2,085 for a family) or 2.5 percent of annual income, whichever is greater. The penalty will be adjusted for inflation beginning 2017.
- Now that most everyone will have healthcare, the coverage is also changing. Things that health insurance companies could pick and choose whether or not to provide are now being required. While from the outset this sounds good, you need to be aware of some common pitfalls about your ‘coverage’ you may not know about (I’ll list them below).
- Anyone under age 26 can be covered with their parents plan (even if you are in college, married, and/or employed). Sometimes this is cheaper, but sometimes it is more expensive to stay on your parents plan than getting on your own health care plan. If you are between ages 18-26, it may be cheaper to be on your own because of the financial help you may qualify for by being on your own plan. I recommend running both numbers to see which will save you the most (this is of course only applicable if your parents are willing to have you on their plan).
- In order to calculate the savings/subsidies each person and family get, the government has instituted a complicated formula which determines that amount. You can find out how much of a subsidy (if any) you qualify for by logging into Healthcare.gov and adding your information. Then you can take these subsidies and apply them towards your health care plan making it more affordable.
- Dental Plans are now required for children under the ages of 18. In 2015 each medical health plan is required to provide one pediatric dental check up per year. This may be all that is covered though so make sure you look at the dental benefits carefully. With dental insurance it is often cheaper (from what I have found) to get insurance privately vs. through the marketplace. But be sure to check. Another good thing to know about dental plans in the marketplace is that they have open enrollment i.e. you can sign up for them at any time of the year (unless it otherwise changes).
- Cost Sharing is a common term used on Healthcare.gov which had me confused. I found out that cost share is a very low co-pay charge for visits and lower deductibles. These discounts are for those who are in a low income bracket and for Native Americans families who make less than a stipulated amount. Sign into Healthcare.gov or call them to find out more about cost sharing qualifications.
When can I or do I have to enroll?
- Health insurance is closed enrollment in the marketplace besides certain times of the year. Open enrollment begins Nov 15, 2014-Dec 15, 2014 and is effective come January 1. The next open enrollment is Dec.16, 2014- Jan. 15, 2015 with the effective date being Feb 1., 2015. Finally the last open enrollment (unless they change it like they did last year) is Jan. 15, 2014-Feb. 15, 2014 with the effective date being March 1st.
- Dental plans in the marketplace have open enrollment i.e. you can sign up for them at any time of the year (unless it otherwise changes).
Can I opt out?
- As mentioned above, the opt out penalty in 2015 per adult is $325.00 ult and $162.50 per child (up to $975 for a family) or 2 percent of annual income, whichever is greater. So yes, you can opt out. But be aware that you will be charged a penalty.
- Some states are allowing everyone to continue on their private insurance plans for one more year. My understanding is that those vouchers are ending at either the end of 2014 or the end of 2015.
Secrets to be aware of before signing up for a plan inside the marketplace.
- Some plans through the marketplace have few in-network providers, do not contain specialists, and have few resources for certain medical aid that the plan is ‘supposed to cover’.
For example: I needed to see a neurologist recently for a nerve disease I thought I may have (I don’t) but the point here is that there was no neurologist in my area of over 5 million that I could be referred to. My general practitioner spent hours searching for one for me but couldn’t find a neurologist that was in-network on my Humana HMOx plan. It was very frustrating to realize that my options in my own state of millions were zero.
For my own family, I found that most general practitioners have opted-out of the marketplace through my insurance. I was sent a provider list of in-network general practitioners from Humana HMOx, and at first it looked hopeful. I had about 40 options. After calling around only 4 were in-network and accepting new patients. Most had opted-out or were not taking on new patients.
IF you want to be extra sure not to fall into the predicament I did, take the time to get a list of providers on the plan you are interested in buying and call the providers, read reviews, etc. so that you know what your options are for real coverage before signing up for that plan.
- I have found a plan inside the marketplace (SelectHealth) that has a much much more extensive in-network provider list and specialists. I will be switching to that in open enrollment. So I’d say the MOST IMPORTANT thing to research before signing up for a plan is the plan’s list of providers. Make sure that the list is large and very comprehensive. And call around to make sure that specific specialists or doctors you can foresee your family needing are in-network and accepting new patients.
- HMO plans- HMO means that you must stay in network unless for an emergency (usually). I am on an HMOx and had to go to the ER. I was charged 100% of it because it was an out-of-network hospital. Most HMOs are supposed to cover emergencies as if they are in-network, but don’t rely on that. So if you do choose to buy an HMO you want to know how big the network is, where the emergency rooms are, how many doctors on their lists are current and accepting new patients, and where in-network clinics are!
- PPO- Means that the plan does cover some out of network benefits. Usually in-network there is an insurance/patient responsibility of 80/20 percent and out of network it is more like 60/40 percent. PPO’s will most likely have higher deductibles to account for their out-of-network benefits.
- POS- Means that the plan does allow out of network options but you will most likely have to go to a primary care doctor to get referrals to see a specialist.
- In some plans you have to meet the deductible before they pay anything, so look out for that, especially if the plan you are thinking about has a very high deductible.
- There are different level of plans that are Bronze, Gold, Silver, and Platinum. These ‘levels’ often determine the monthly premium and benefits offered. I went for the platinum plan because it has a low deductible and out of pocket maximum. But what I didn’t know is that I would be enrolling in a very limited network. So by the end of this year I will have paid significantly more than the $1,500 out of pocket maximum stipulated by my plan because I was told I could see certain doctors and later found out the information was incorrect. They were not in-network as I was informed. This out of pocket amount does not include the premiums I was paying monthly for the ‘platinum’ plan.
- Just because you choose a Platinum plan doesn’t mean it will have the care you are expecting to receive for the price you are paying. You need to do your homework before choosing a plan.
- Look into co-pays for doctors and specialists. My brother-in-law went into see a specialist and for the co-pay alone it was $150.00. That did not include the bills that came after the co-pay, the labs, etc. So be sure to look at the amount you are responsible for on the co-pays.
- Be aware that many of these plans have high deductibles and they are in many cases rising. I logged in to choose a plan for 2015 and last year my plan had a deductible of $1000.00 but this year I’m seeing that many options for low deductibles are much more expensive.
- Sometimes it is cheaper to just pay cash for prescriptions than to go through your insurance. This was the case for me when I tried to get a prescription filled and they informed me they wouldn’t take my insurance. They said I would have to drive across town to a pharmacy that accepted my insurance. I asked how much it would be if I just paid cash and they said 9 dollars. I couldn’t believe it. I would have paid more than that for my prescription copay. Of course, if you pay cash it doesn’t go toward your deductible so just be aware of that.
- Plans are required to pay for preventative care, but besides that many plans don’t pay for anything until you have reached your deductible (if it is not preventative).
- If you or a member of your family had some type of catastrophe happen, you would be in charge of a certain percentage of the bills until the out of pocket maximum has been met. Please be aware of the out of pocket maximum number.
- If you are not happy with the service/providers/or insurance company you are with you can switch over to a new one during the open enrollment date.
- If your employer offers you insurance you cannot go through the exchange to get insurance.
- You must include your correct income. If your income is more than what you claim, you will be required to pay back either a portion of or all of the tax credits you received throughout the year. This will happen when you file your income tax. So be sure to report your income honestly in order to have the most accurate picture of what your plan will cost you. These are some of the things to consider when reporting your income:
- Wages-Don’t include as income any money that an employer takes out of your paycheck for child care, health insurance, or retirement plans that is “not taxable.” Sometimes these are called “pre-tax deductions.” Your pay stub should list these deductions individually.The pay stub may list your “federal taxable wages.” If it does, use that figure to report your pay.
- Net income from any self-employment or business (generally the amount of money you take in from your business minus your business expenses)
- Unemployment compensation
- Social Security payments, including disability payments — but not Supplemental Security Income (SSI)
- Other items to include when estimating your 2015 income are: retirement income, investment income, pension income, rental income, and other taxable income such as prizes, awards, and gambling winnings.
- Disaster plans do not count as the insurance requirement inside the Marketplace. Some families have found the marketplace to be too expensive for their budget so they are keeping their very high deductible disaster plans and just paying the penalty fee. It may work out to be cheaper to do this if you can’t afford Obamacare but still want some sort of protection in case of an expensive medical emergency.
While some are happy about the Affordable Health Care Act and others are downright furious, it was passed into law and it is what it is. I have seen lots of cons and some pros. Others have seen lots of pros and some cons. This post is just to inform and empower you with information you may need to make the best decision on health care for you and your family!
Any warnings, cautions, stories, advice, questions, etc. you want to share or ask about Marketplace Healthcare? If so please comment below.
Be sure to read how to save on general medical expenses here. If you or anyone in your family has a prescription, Download the SearchRX app. It will show you based on area the cheapest place to fill a prescription at and also if there are any available coupons and read 14 Ways to Save Big on Prescriptions.
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