FAQs Major Medical

FAQs about Individual and Family Health Insurance

Q: What is the difference between private health insurance and enrolling in a plan on the Federally Facilitated Marketplace?

A: Choosing to purchase insurance on the exchange allows you to use your tax refund for 2016 to help pay for your premium each month.  These plans are also guaranteed to you without medical underwriting.  Plans outside the exchange will cost more, probably require a physical or more medical information, and are not necessarily guaranteed.

Q: Since I can go onto the Federally Facilitated Marketplace myself, what would be the reason to contact you instead?

A: There are many little pitfalls within the questions the Marketplace asks.  If you answer incorrectly you could be denied your tax credit subsidy, pay more for your health insurance, or not be eligible for the plan you would like.

Q: What do the categories or metal tiers I hear about mean?

A: There are 5 categories in the marketplace and off exchange plans are also using these too.  They are referred to in metal tiers.

  • Bronze which will have the lowest premiums each month but you will pay more in co-pays and co-insurance.  Typically the insurance companies will cover 60% of the expenses and you will pay 40% in addition to your premiums.
  • Silver level has a slightly nicer benefit package.  Your premiums will be a bit higher but your out-of-pocket costs will be a little less. In this level insurance companies cover 70% or the expenses and you pay 30% in addition to your premiums.
  • Gold plans have an even higher premium level but your costs are less.  You will pay 20% of your costs while insurance companies will pay 80%.
  • Platinum is the highest level of insurance care your can purchase.  With the higher premiums your care is mostly covered.  You will pay 10% of expenses while the insurance company pays for 90%.
  • Catastrophic plans are available to those 30 or who have a hardship exemption.  They pay less than 60% of the total cost of your care coverage.

Q: Do the benefits vary a lot by insurance provider, either on or off the marketplace?

A: The benefits do not vary much.  By law all plans are now required to provide the same key essential benefits.  The difference is noticed in how the different insurance carriers cover that benefit service and how much you’ll pay for.  Marketplace plans are also required to cover pre-existing conditions and provide preventive services.

Q: Can I go to any doctor I want?

A: Most insurance carriers require you to select a primary care physician and stay within their network of contracted doctors.  If you choose to go outside that network your pay for most, if not all, of your care.  There are some plans that will allow you to go outside of the network and still over coverage but you will still pay a higher co-pay or co-insurance than staying within the network. Before enrolling in a plan be sure to double check the doctors in that plans network.