CHOOSING HEALTH INSURANCE?
First, we need to consider the purpose of insurance, specifically HEALTH INSURANCE.
The purpose of an insurance policy is to provide you with financial protection from losses (expenses) resulting from the insured ‘event’ occurring within the policy’s specified time frame. In the case of property, your insurance will pay the cost of replacing your lost or stolen possessions; in the case of auto insurance, you will be covered for the cost of repairing the damage to your own and other vehicles or property damaged in an accident (if it was your fault.) If the event was not your fault, one of the other party’s insurances will pay.
With auto and property insurance, you can choose a plan that commits to paying a proportion of any claims you make. The more significant the proportion of your claim you agree to pay, the lower your insurance policy’s annual or monthly premium will be. This makes sense but can be very expensive if you have to make a large claim.
Health insurance works the same way, but there is one significant difference. All ACA-compliant plans include certain preventive services entirely free of charge. Regular screenings and other preventive measures make sure your children have the best chance of a healthy start in life and can help you avoid future, expensive, and possibly life-affecting conditions such as cancer and coronary diseases.
It is rather like having your car serviced at the government’s expense. After all, a regularly serviced car is less likely to cause an accident or need expensive repair.
There are hundreds of health insurance companies (providers) and literally thousands of plans, each designed to meet the expectations of individuals or families with specific needs.
Not all these plans are available in every state or county. That is the first good reason for talking to a qualified health insurance specialist with local knowledge.
THE METAL TIERS, WHAT DO THEY TELL US?
The metal tiers—Bronze, Silver, Gold, and Platinum—indicate how the risk (the cost) will be shared when you make a claim on your health insurance and the cost-sharing reductions to which you will be entitled. To be absolutely clear, the metal tier you choose has no influence on the quality of care you receive.
The cost splits are averages, based on the whole insured population. Your exact costs will depend on the nature and type of services you receive.
All ACA-compliant plans, whatever their metal color must cover the ten essential services: –
Essential Ambulatory patient services (outpatient care)
Emergency services
Hospitalization (inpatient care)
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Prescription drugs (including brand-name drugs and specialty drugs)
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care
Other services depend on your personal plan choice. Each plan comes with cost-sharing choices (the metal tiers): –
Bronze: The insurer covers about 60% of healthcare expenses, and you are responsible for the balance of 40%. These plans have the lowest premiums but the highest share of out-of-pocket costs when care or medication is needed.
A bronze-tier plan could suit you if: –
- You are rarely sick and in need of medical services, apart from an annual checkup and only occasional medication.
- You and any member of your household on your plan are very healthy and not elderly.
- You are buying a family plan, and your children are grown and healthy and do not participate in risky pastimes not otherwise insured.
Silver: The insurer pays about 70% of healthcare expenses, and you pay 30%. Silver plans have moderate premiums and, in many states, attract the most favorable cost-sharing reductions (CSRs) out-of-pocket costs.
A silver-tier plan might be appropriate if: –
- No one in your family has a chronic (long-term) condition. Family members have one or two mild conditions that require some medication and specialist visits but nothing needing close monitoring or frequent care.
- Your family members are generally fit and under and under 70.
- Any children in the plan are elementary age or older, healthy, and not regularly involved in activities that often cause injury.
Gold: The insurer covers around 80% of healthcare expenses, leaving you to meet the remaining 20%. Gold plans have higher monthly premiums but lower out-of-pocket costs when need care.
A gold plan may be the right plan if: –
- You or a family member has a chronic (long-term) condition, e.g., an allergy, that requires frequent interventions, hospital visits, or doctor visits. Expensive medication or care might not be possible to afford out of pocket.
- You have children who are preschool age or younger and need frequent pediatrician visits.
- You may be older or at a higher risk for colds and flu than most people.
Platinum: Your insurance company pays approximately 90% of healthcare expenses, and you pay 10%. Although platinum plans have the highest monthly premiums, they also have the lowest out-of-pocket costs.
A platinum plan may seem expensive but should be considered if
- You or a family member has an expensive chronic condition and needs long-term or multiple medications.
- You need urgent or emergency care more than once per year on average, frequently need exams to manage a condition, or see doctors more than once per month.
- You are older or at very high risk for colds, flu, or injuries e.g., falling.
WHERE CAN I GET IMPARTIAL ADVICE?
Health insurance companies (providers) compete to offer the lowest prices and the best network of doctors, consultants, and pharmacists. Each one boasts that it offers the best, most flexible, and fastest administrative service. Not all of them will offer their plans in your county or state. Who will give you unbiased advice when it comes to insuring your family’s healthcare?
Your best source of advice is a qualified independent health insurance broker or agent with well-founded local knowledge; knowledge could save you $thousands and cost you nothing.
HOW CAN I BE SURE THAT THE ADVICE IS IMPARTIAL?
Independent agents and brokers are paid on commission. That commission is the same whichever insurance provider you choose. Your best interests are your broker’s best interests.
