You have a choice of On Marketplace plans and Off Marketplace plans.
ON Marketplace Plans: On Marketplace plans are Subsidy Eligible plans. If your Modified Adjusted Income. Is 400% or less than the Federal Poverty level, you are eligible for a subsidy. Do not assume you are not eligible. Go to; kff.org/interactive/su Run your MAGI and let the calculator tell you. You can purchase an On Marketplace plan even if you are eligible for a subsidy. If your income is between 139% and 250% of the poverty level, you may also qualify for cost sharing. The only plans with cost sharing are the Silver plans and depending on your MAGi , you may qualify for a reduced deductible and Maximum out of Pocket.
Off Marketplace Plans: Off Marketplace plans are not subsidy eligible and you will not be able to receive any subsidies or cost sharing if you purchase an Off Marketplace plan.
DEDUCTIBLE: This is what you pay before the insurance company starts paying for covered services.
MAXIMUM OUT OF POCKET: The total amount of your bill you are responsible for before the insurance company will pick up 100% of your covered claims.
Two types of Deductibles and Maximum Out of Pocket :
Embedded Deductible and Maximum out of Pocket: When one family member meets his or her deductible, that person then moves to coinsurance portion of coverage and you are responsible for a portion of your claims until that family member meets his or Her Maximum Out of Pocket. Embedded deductible and Max Out of Pockets are capped at 2 family members, then all family eligible claims are paid at 100% for the rest of the year. Most Gold Saver and Bronze Non HSA plans have an embedded deductible.
Family or Aggregate Deductible and Maximum out of Pocket: You are responsible for r all of your network discounted claims until 12 family member or a combination of family members meets your Aggregate or family deductible . If your plan has coinsurance, you pay your coinsurance percentage until the Family Max out of pocket is met. Only then, are your claims paid at 100% . Most HSA compatible plans have a Family deductible. The best way to tell if the plan has a Family deductible is look at the plan name. The Market HSA 4000-Bronze, has a deductible of $8000. This indicates a Family deductible ( 2 x 400)
YOU MUST CHECK THE NETWORK BEFORE YOU APPLY FOR ANY PLAN
Before you complete an application for any company, you need to verify your doctors and hospitals are In-Network for the plan you choose. Most companies are shinnying down their networks for the new ACA plans. Some companies have set up new networks for the new plans. Just because your doctor is in-network for your current plan, does not guarantee they will be in network for an ACA plan. Just because your hospital is currently in-network , you cannot assume it will be in the new network.
HEALTH SAVINGS ACCOUNT: ( HSA)
You must have an HSA compatible health plan to set up an HSA savings account. An HSA savings account allows you to deposit funds in a savings account, take a tax deduction and use your HSA account to pay for your medical expenses with pre-tax dollars. You can purchase an HSA compatible plan, and use it as a traditional plan without establishing an HSA savings account.
Please Call David Randolph 440-734-4629 or 1-800-822-4629 if you have any questions or need any clarification of these terms.