Obamacare or marketplace insurance can be super confusing. I mean before Obamacare I found health insurance pretty bewildering anyway, but the creation of the Affordable Care Act made it even more confusing for me. And, when it comes to women’s health, insurance isn’t something that is always in our favor. Especially, if you have what insurance companies deem to be a pre-existing condition such as pregnancy, chronic illness, or cancer. You’re going to quickly find that health insurance is not always on your side and medical bills and expenses add up quickly. Which makes finding an affordable plan that covers women’s preventative care, prescriptions, and additional necessary medical expenses a headache.
Now, I’m no health insurance expert BUT, these past couple of years I’ve seen the good, the bad, and the absolute ugly when it comes to medical expenses, and health insurance. So, I wanted to start a series that facilitates awareness and discussion regarding key points that we as women need to understand when we’re choosing health insurance plans. For certain, these are things that I wish I knew and understood more clearly.
What is Obamacare and the Affordable Care Act About?
First up, I want to talk about the Affordable Care Act and Obamacare (Marketplace Insurance). Since we are in the midst of open enrollment and chances are you may be shopping for a new health plan I’m hoping this article can be helpful. If you’re like me you perhaps didn’t really understand the purpose or the mechanics behind the Affordable Care Act. Essentially it was a law created to make health insurance affordable and accessible for everyone. It set out to accomplish this by providing subsidies (premium tax credits) for those that qualify. These subsidies help decrease the cost of insurance for families and households that are living below the federal poverty level.
Additionally, the Affordable Care Act expanded coverage to Medicaid programs which cover adults that have an income 138% below the poverty level. The act also included changes that impacted how insurance treated those with pre-existing health conditions. It was common for many insurance companies to deny coverage to those that have chronic illnesses, cancer, and pregnancy. Or, if they were allowed coverage they were stuck with paying a ton of out-of-pocket expenses and got little to no coverage for treatments, prescriptions, surgeries, etc.
How to Sign Up for Coverage: Open Enrollment
Obamacare has specific times of the year for which you are allowed to choose and enroll in health coverage for the year. This time period typically occurs from November 1st-December 15th and you can expect your coverage to start on January 1st. Outside of this time period, you’re only allowed to switch or enroll in marketplace insurance if you have a qualifying life event such as:
- Getting married
- Getting divorced
- Becoming pregnant
- Losing health insurance coverage (e.g. getting laid off, or quitting a job)
- Moving to a new area
If you fail to choose insurance by the deadline or if it becomes too much for you to pay and one of two things occurs. One, you decide to cancel the insurance. Or, two you cease making payments and lose coverage. Either way, you’re not eligible to choose and enroll in another marketplace insurance plan. You’ll have to wait for open enrollment to come around again if you want major medical insurance. Or, you may decide to choose an indemnity insurance plan which is not part of the Affordable Care Act and usually have their own policies, and rules. Primarily, these plans are more suited for those that have very general health care needs and rarely visit the doctor. They’re also best suited for those that do NOT have pre-existing conditions. But, we will discuss this type of insurance coverage in a future article.
Obamacare & Women’s Health
I know first-hand how easy it is to allow your health and wellness to fall to the wayside and put off going to the doctor and taking care of yourself. This can be due to time, financial strain, lack of adequate coverage, or anxiety when it comes to visiting the doctor. But, making preventative health a part of your self-care routine and making time to go to the doctor is necessary. And, if you found that you were sacrificing your health due to money or inadequate insurance coverage, Obamacare has made access to preventative health services more readily available.
At this current time, preventative health services are mandatory under the Affordable Care Act. This means that each year you’re allowed one free well-woman exam which is focused on assessing your current state of health and identifying any potential issues. Examples of preventative services that can be performed during your exam include:
- Assessing your blood pressure
- Performing a breast exam
- Measuring your height and weight
- Pap smear and pelvic exam
- Cancer screening
- HPV screening
- HIV and STD screening
- High blood pressure and cholesterol screening
- Diabetes screening
- Osteoporosis screening
- Depression screening
- Domestic abuse screening
- Colon cancer screening (if you’re over 50)
- Mammograms (every 1-2 years if you’re over 40)
- Provide applicable immunizations when necessary
Pre-Existing Conditions (Pregnancy, Chronic Illness, and Cancer)
This past year struggling with a plan that offered such limited coverage taught me a lot about the benefits of having major medical insurance. Needless to say, I regretted not meeting the deadline and choosing a marketplace insurance plan when I had the opportunity. If you have any type of pre-existing condition you are definitely going to want to enroll in a major medical insurance plan. You won’t be denied coverage and you won’t have to pay extra because of your condition. The combination of your coverage level and plan type will determine your out-of-pocket expenses. But, we’re going to go over that later in the post.
Right now, let’s talk about how Obamacare is helpful for those with a pre-existing condition. As I explained earlier, you won’t have to worry about being denied coverage or being made to pay more since marketplace insurance is income-based rather than health-based. If you’re eligible for a premium tax credit you can apply those savings to a higher level of coverage which may be better suited for your unique health needs.
Depending on the level of care required for your condition you can expect lower out-of-pocket costs for doctor visits, help with prescriptions, and higher percentages of coverage from your insurance company. This means you’ll be responsible for significantly less as it relates to ongoing medical care. Although Obamacare is beneficial for those with pre-existing conditions, it’s important to note that it’s not perfect. It does help to decrease and lower costs BUT, medical expenses are still no joke. Especially if you are referred to various specialists, require multiple surgeries or you’re managing multiple chronic conditions. While it’s helpful it’s still not a perfect solution for those with chronic conditions and illness.
Choosing Your Obamacare Plan
Now, that we’ve discussed some basics concerning the Affordable Care Act and Obamacare insurance. It’s time to discuss what you should look for when you’re enrolling for healthcare coverage this year.
Let’s Talk Levels
Remember when I was talking about there being different levels of coverage? Well, now we’re about to dive into the four levels of coverage offered within Obamacare. An easy way to think of these levels and rank them is to compare them to Olympic medals. You have the bronze level, silver level, gold level, and platinum level. The purpose of these levels is to assign how you and your insurance companies are going to split the bill for medical expenses.
Here are some fast facts about the bronze level:
- The insurance company is responsible for 60% of medical expenses
- You’re responsible for 40% of your medical expenses
- Typically have higher deductibles
- Lowest monthly cost
- Higher costs out of pocket for frequent medical care and progressive medical treatment
Generally speaking, the bronze level is ideal for someone that doesn’t necessarily require a lot of coverage. If you require basic coverage and want to reap the benefits of having preventative care services covered this would work for you.
As for this level here’s what you can expect:
- The insurance company is responsible for 70% of your medical expenses
- You’ll be responsible for 30% of your medical expenses
- Expect moderate monthly payments
- Mid-level deductibles
- Look to slightly elevated out of pocket costs for progressive medical care
This is a good fit if you require routine care but aren’t expecting to encounter frequent doctor trips or need to see a variety of different specialists. It may also be ideal for those with chronic conditions that are managed and don’t require more progressive care.
With this level you will benefit from:
- The insurance company paying for 80% of your medical expenses
- You get to enjoy paying 20% of your medical expenses
- Expect higher monthly payment
- Lower healthcare costs
- Decreased deductible
If you’re expecting to incur more medical expenses during the year then this coverage plan would be the best. It’s ideal for those that are expecting to become pregnant or that already are pregnant. Additionally, it is beneficial for those that are managing a chronic condition that requires frequent doctor visits, and routine care.
The benefits you can expect from this level include:
- Insurance covering 90% of your medical expenses
- You are responsible for the remaining 10% of your expenses
- Highest monthly payment of any level
- Lowest health care costs of any level
- Lowest deductibles of all levels
This plan is ideal for those that are anticipating the need for more involved medical care. Such as managing a high-risk pregnancy, chronic conditions, cancer treatments, surgical procedures, and advanced medical treatments.
Time to Explore Plan Types
The type of plan that you decide to go with will affect which medical professionals, hospitals, and providers you’ll see. Additionally, your plan determines if and how much your insurance is responsible for as well as how much you’re responsible for paying out of pocket. Let me explain these different plan types so you’ll have a better idea of what each plan has to offer.
Exclusive Provider Organization (EPO)
With this plan, your medical care services are covered by the doctors, specialists, and hospitals that are affiliated with their network. In other words, your medical expenses are only covered by medical professionals that are part of a specific network created by the insurance company. If you go to a doctor or specialist that’s outside of this network, you would be responsible for any and all out-of-pocket expenses. The only exception to this rule is in the case of an emergency situation.
Health Maintenance Organization (HMO)
An HMO is a plan that limits coverage you receive to the doctors and medical professionals that are part of the insurance company’s organization. Meaning that you will only be able to receive your medical services from the doctors and specialists that “work with” or are “contracted” with the HMO. They typically require you to live or work in the coverage area in order to meet their eligibility requirements. And, they do not cover out-of-network care except in the case of emergencies.
Point of Service (POS)
This plan type allows you to pay less when you receive medical care from doctors, hospitals, and providers within their network. You will normally have a set primary care physician (PCP) that you will see for the majority of your health needs. And, in the case that you need to see a specialist, you MUST get a referral from your PCP first.
Preferred Provider Organization (PPO)
Lastly, this type of health plan allows you to pay less when you stick to doctors and health care providers within the insurance company’s network. And, similar to a POS type of plan you’ll have a PCP and will need a referral to see a specialist. Typically, if the specialist or provider that you’re going to is out of the network. Receiving medical care from doctors, hospitals, and providers without a referral from your PCP will lead to higher costs.
The Struggle of Choosing A Plan
Unlike choosing which level is going to work best for you choosing a plan type can be a bit of a doozy. The fact that there are various limitations, rules, and exclusions to each can make your head spin. A good place to start would be to identify who you’re currently getting medical care from. If there are specific doctors that you’re working with you can see which plan type they’re associated with and decide if it’s something you want to commit to for your health insurance.
Generally speaking, if you don’t require a ton of medical coverage choosing a plan such as a PPO, POS, or EPO would work fine for you. Especially, since you’re most likely only going for preventative care and not routine doctor visits. There is way more flexibility regarding which healthcare plan you choose. Whereas, if you need more routine care and see specialists outside of your PCP an HMO, EPO or PPO might work better for you. You would have to be mindful of whether or not certain specialists are part of your plan’s network. But, again this is just my opinion. I’m not a health insurance expert and I definitely don’t have it all figured out. Just offering guidance and insight from what I’ve learned so far in my health journey.
So I Think That’s It?…
Wow, that was a lot of information. And, I still feel as though there’s so much more I could talk about. But, this is pretty much the meat and potatoes as it relates to Obamacare and marketplace insurance. Thankfully there’s still time to review different Obamacare plans and decide what would work best for you (you have until December 15th).
Preventative Care is Required By LAW
This is super important to remember. You don’t have to pay out of pocket for preventative health services with marketplace insurance. Additionally, you’re not required to reach your deductible before receive preventative care services. You’ll receive one FREE well-woman exam each year. And, unless there is diagnostic testing that needs to be done you don’t have to anticipate any out-of-pocket expenses.
Do You Have Specific Health Care Needs?
Are you pregnant or planning to become pregnant? Do you have a chronic illness or cancer that you are treating? How frequently do you visit the doctor? Do you have a team of doctors and specialists? All of these questions are important when it comes to choosing your health insurance. Depending on the level of care that you need will determine your level of coverage as well as the type of plan you go with.
Read the Fine Print
Don’t jump into a plan just because it’s cheap. I’m calling myself out here because I’ve been so guilty of doing this. Make sure you read up on what the plan covers, deductibles, co-insurance, prescriptions, and plan limitations. Also, look into whether your current doctors and medications are covered by the plan you’re considering. Things can look good on paper until you dig into the details and realize that it’s not so good.
Consider Your Budget
Ok, this is probably super obvious but you want to make sure that you can commit to paying for your insurance each month. While premium tax credits are available to those that qualify and can be applied towards the amount you’ll pay each month. Making sure that the plan you choose aligns with your budget will ensure you’re able to get quality care throughout the year.
I know for those with chronic illness, or health conditions this can be a difficult decision. Typically the plans that offer the best benefits are more pricey. Focus on choosing the one that offers what you need for the year without wrecking your wallet. If you’re not anticipating a major surgery, or need routine care you can get by with a lower level plan. Additionally, if your main concern is prescription coverage there are various programs( like Good RX) that help make prescriptions more affordable.
That’s All Folks!
Alright, I think I’ve covered it all. I truly hope you found this helpful. Let me know if you did and leave a comment below. I also include some helpful resources that you may find helpful to learn more about marketplace insurance. Also, if you’re a super health insurance ninja and have some tips you want to share please do! Leave a comment below I’d love to hear from you!