What are the main types of health insurance plans?

• HMO (Health Maintenance Organization): These plans typically require you to choose a primary care doctor who provides referrals for specialists, and generally only cover care received within their network.

• PPO (Preferred Provider Organization): PPOs offer more flexibility, allowing you to see specialists without referrals and providing some coverage for out-of-network care, though at a higher cost.

• EPO (Exclusive Provider Organization): EPOs generally require you to stay within their network for coverage (except emergencies) but often do not require referrals to see specialists within that network.

• POS (Point of Service): POS plans combine aspects of both HMOs and PPOs, usually requiring a primary care doctor and referrals for in-network care, while also offering coverage for out-of-network services at a higher cost.

What is a deductible, copay, coinsurance and out of pocket maximum?

• Deductible: This is the amount you pay out of your own pocket for covered medical services each year before your health insurance plan begins to pay its share.

• Copay (Copayment): A flat, fixed fee you pay for a specific medical service, like a doctor's visit or a prescription, usually paid at the time of service.

• Coinsurance: This is the percentage of the cost of a covered medical service that you are responsible for paying after you've met your deductible.

• Out-of-Pocket Maximum: The absolute most you will have to pay for covered healthcare services in a policy year; once you reach this limit, your insurance pays 100% of additional covered costs.

When can I enroll in coverage?

The primary time for most people to enroll in ACA Marketplace plans is during the annual Open Enrollment Period, which typically runs from November 1st to January 15th for coverage starting the following year. If you miss this period, you might still qualify for a Special Enrollment Period if you experience a significant life event like losing other coverage, getting married, or having a baby, usually giving you 60 days to enroll. Lastly, certain Year-Round Enrollment options are available directly from private insurance companies, such as short-term health plans, which can be purchased anytime but generally offer more limited coverage and may not cover pre-existing conditions like ACA-compliant plans.

Can I get health insurance if I have a pre-existing condition?

Yes, in most cases, absolutely! Thanks to the Affordable Care Act (ACA), health insurance companies generally cannot deny you coverage, charge you more, or refuse to cover treatment for a pre-existing condition.

I do not want a Marketplace plan. What are my other options?

If you don't want a Marketplace plan, other private options include Short-Term Health Insurance (temporary, often no pre-existing condition coverage), Direct-to-Carrier Plans (ACA-compliant but no subsidies), Health Care Sharing Ministries (cost-sharing based on beliefs, not traditional insurance), and Fixed Indemnity/Limited Benefit Plans (pay fixed amounts for specific services, not comprehensive). Remember, these alternatives offer varying levels of coverage and protections.

What information do I need to provide to get a quote?

You'll typically need to provide your zip code, the birth dates and household size of everyone needing coverage, your estimated household income (especially for ACA Marketplace plans to determine subsidies), and your smoking status. For some private plans outside the ACA Marketplace, you might also be asked about your medical history.

Why is it beneficial to work with a health insurance broker?

Think of a broker as your personal guide through the complexities of plans and options, all while working at no direct cost to you. A good broker's goal is to truly understand your unique needs and budget so they can help you confidently navigate the choices – from understanding different plan types like HMOs and PPOs to finding out if you qualify for financial assistance. They'll do the legwork, researching and comparing policies from multiple carriers, ensuring you find a plan that not only fits your needs but also offers great value. Beyond just enrollment, a broker is there to provide ongoing support, whether you have questions about your coverage, a bill, or just need a clear explanation.