Starting Nov. 1 and ending Dec. 15 (in most states), uninsured Americans can sign up for coverage under the Affordable Care Act or renew the coverage they already have.
If you want coverage in 2019, you must enroll during these 45 days unless you later have a qualifying life event, such as getting married or divorced.
Some younger and healthier people may not think coverage is worth the monthly premiums.
But think again, says Gerald Kominski, a professor of health policy and management at UCLA.
“There’s the idea that ‘I take care of myself, I live a healthy lifestyle, I eat well, I don’t smoke — I’m going to be healthy and live forever,’” he says. “Nobody knows what the future holds. People with perfectly healthy lifestyles get sick every day.”
What’s New This Year Under the Affordable Care Act
For the first time since the Health Insurance Marketplace — a federally run service where people can shop for and enroll in private insurance — opened five years ago, Americans will not have to pay a financial penalty for failing to obtain insurance. But experts say it’s still critical to buy coverage.
It costs up to $7,500 to fix a broken leg, about $30,000 for three days in the hospital and into the hundreds of thousands of dollars to treat cancer, HealthCare.gov says. The average visit to an emergency room in 2016 cost $1,917, according to the Health Care Cost Institute.
Most working people can’t cover that kind of expense with their salaries or savings, says Kominski — who, three decades ago as a graduate student, needed an appendectomy that cost $15,000. Because he had a student policy, he says, his share was less than $100.
In addition, health insurance plans that provide free or low-cost preventive services and promote the early identification of problems reduce the likelihood that more expensive and extensive treatment will be needed later, said Jay Wolfson, professor of public health, medicine and pharmacy at the University of South Florida. Thus, they benefit even people who are healthy — or appear to be.
And when healthier people buy insurance, it costs less for everyone, he said.
How To Shop For an Insurance Plan in the Marketplace
Start by going to HealthCare.gov and clicking “get ready to apply” if you plan to enroll for the first time or “get ready to keep/change” if you had a 2018 plan through the Marketplace, also known as the “exchange.”
Some states operate their own exchanges. If you live in California, Colorado, Connecticut, Idaho, Maryland, Massachusetts, Minnesota, New York, Rhode Island, Vermont, Washington or the District of Columbia, you must apply through your state.
Application deadlines are slightly later in California, Massachusetts, Minnesota and Rhode Island, so be sure to call or check your state exchange’s website. In general, coverage begins Jan. 1, 2019.
Online, you’ll learn how to estimate your 2019 income for the application and find a checklist of information you’ll need, such a such as household size, the Social Security numbers and birthdates of your family members, W-2 forms or pay stubs and policy numbers of any current health insurance. Coverage is available only to U.S. citizens and legal residents.
With insurance through the Marketplace, you’ll pay a deductible and coinsurance — a percentage of a covered health service — of 10% to 40%, depending on which plan you choose. You’ll have to pay only up to an out-of-pocket maximum, and there are no yearly or lifetime dollar limits.
You’ll also get the benefit of discounts that insurance companies negotiate with health care providers. People without insurance pay almost two times as much for care, according to HealthCare.gov.
How to Apply, What’s Covered and What Help Is Available
You can apply by phone, in person with help from a navigator — a person specially trained to walk you through the process — through an agent or broker or by mail with a paper application. Volunteers certified by the Marketplace also may be available through nonprofit organizations such as community health centers or hospitals.
Coverage through the Health Insurance Marketplace is intended for those not covered by insurance at work or by government programs such as Medicaid, Medicare, Tricare (for members of the military, veterans and their families) or CHIP, the Children’s Health Insurance Plan.
Plans that comply with the Affordable Care Act, often called Obamacare, cannot discriminate against people with pre-existing conditions. They also must cover birth control and breastfeeding equipment and counseling, plus 10 “essential” services:
- Outpatient care.
- Emergency services.
- Hospitalization.
- Pregnancy, maternity and newborn care.
- Mental health and substance abuse services.
- Prescription drugs.
- Mental and physical rehabilitation for people with injuries, disabilities or chronic conditions.
- Laboratory services.
- Preventive and wellness services and chronic disease management.
- Pediatric treatment, including dental and vision care.
You’ll pay different premiums and out-of-pocket costs depending on the plan you choose. The government will subsidize your premiums if your income is between 100% and 400% of the federal poverty level.
Currently, that’s $12,140 to $48,560 for a single person and $25,1000 to $100,400 for a family of four. Income eligibility levels are expected to rise slightly for 2019; the new figures won’t be available until Nov. 1, 2018.
The lower your income, the higher the premium tax credit you’re eligible for (i.e. the help you’ll receive).
What Kind of Plans Are Available?
Insurers sell plans in four categories: Bronze (the least coverage and the lowest premiums), Silver, Gold and Platinum (the most coverage and the highest premiums). Depending on where you live, you may find several types of plans at each level.
You’ll want to make sure your doctors are in the plan you choose and that your prescription medications are covered.
You may have a choice of:
- An exclusive provider organization (EPO), which covers services provided only by doctors and hospitals in a network, except in an emergency. You aren’t required to choose a primary care provider.
- A health maintenance organization (HMO), which requires you to obtain care from doctors who work for or contract with the HMO, except in an emergency. You may have to live or work in the HMO service area.
- A point of service plan (POS), which charges less if you use health care providers that belong to a network and requires you to get a referral from your primary care doctor to see a specialist.
- A preferred provider organization (PPO), in which you pay less for in-network providers, but you can go to out-of-network providers for an additional fee. You don’t need a referral to go to a specialist.
Average unsubsidized premiums vary widely from state to state. The price of the Silver plan for a 27-year-old single nonsmoker ranges from a low of $278 per month in Indiana to $709 per month in Wyoming, according to the U.S. Centers for Medicare and Medicaid Services.
The figures apply only to the 39 states that use the HealthCare.gov platform. About 9 million people have coverage through those exchanges, according to the federal government.
Catastrophic Insurance
Catastrophic insurance is another alternative available to people younger than 30 and those who can claim a hardship exemption, such as homelessness, domestic violence or bankruptcy. You must apply for the exemption.
On the upside, catastrophic plans cover the 10 essential health benefits, offer specific preventive services for free and cover at least three visits to a doctor annually before the deductible is met. They also cost about one-third as much as more comprehensive plans.
The large downside is that the deductible — the amount the patient has to pay before the insurance company starts sharing the cost — is $7,900. Additionally, these policyholders aren’t eligible for a premium tax credit.
Kominski of UCLA suggests that consumers compare the coverage and cost of a lower-tier plan in the Marketplace before choosing a catastrophic plan.
Coverage That Doesn’t Meet Affordable Care Act Standards
As of Oct. 1, 2018, low-cost health policies became available for a one-year term, renewable for up to three years. Previously, they were sold for a three-month period of coverage only, and were considered stopgap insurance plans for people between jobs or otherwise temporarily without insurance.
It’s important to be aware that these policies don’t comply with the mandates of the Affordable Care Act, meaning they don’t have to cover people with pre-existing conditions or pay for any of the services the act deems essential.
Kominski warns that low-cost policies may seem attractive — until you need medical care. He compares them to a car that’s cheap, but only because it doesn’t have airbags or comply with air-quality standards.
“If you’re shopping for price, you’re going to get what you pay for,” he said. “If you want to expose yourself to risk, we can make health care really affordable.”
Susan Jacobson is an editor at The Penny Hoarder. She also writes about health and wellness. Follow her @SusanJacobson44.
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