What Is the Health Insurance Exchange? | UPMC HealthBeat (2024)

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Shopping for health insurance can seem confusing or frustrating at times. It’s a major commitment, and you want to make sure you’re making the best, most well-informed decision for yourself and your family.

Luckily, if you are looking at how to acquire health insurance, there’s an easily accessible, organized way to approach this challenge: you can shop for health insurance through your state’s health insurance exchange or health insurance marketplace. The marketplace is an online resource that lets you compare available plans and prices in your state and then enroll in a plan online.

How to Navigate the Marketplace

Generally, you can sign up for health insurance through the marketplace only during the annual open enrollment period, which typically starts in November and ends in December. If you want to sign up outside of the open enrollment period, you need a qualifying reason, such as:

• Having a baby or adopting a child
• Getting married or divorced
• Changing jobs

Once you’re online, the first step is to select the state where you live and enter some basic information, including:

• Age
• Income
• Number of people in your household

You’ll find out if you qualify for a premium tax credit and how much it may be, and then you’ll see a list of plans to evaluate and compare.

Understanding Health Insurance Terms

It helps to understand basic terms used by health insurance plans as you begin to compare them, such as:

• Premium: This is how much you pay each month for insurance coverage.
• Deductible: This is how much you pay out-of-pocket for health services before your insurance starts to pay some of the bill.
• Coinsurance: This is the percentage of the bill you pay after meeting your deductible—for example, your coinsurance may state that you pay 30 percent of the bill, while your insurance pays 70 percent
• Copay: This is a set fee you pay for a medical service, such as $20 for an office visit. This amount often does not count toward your deductible amount.
• Out-of-pocket maximum: This is the maximum amount you would be expected to pay for medical care each year. In 2018, it was $7,350 for an individual.

Evaluating Plans on the Health Exchange

The number of available plans varies by state, but you can begin to narrow your search by deciding between a bronze, silver, or gold plan.

• Bronze plans have the lowest premiums with high deductibles, and they also have high out-of-pocket maximums.
• Silver plans have a higher monthly premium but a lower deductible.
• Gold plans have the highest monthly premium, with the lowest deductible.

What may be best for you depends on your use of health care services.

• How often do you visit the doctor each year?
• What does that cost you now?

Remember that preventive care, like an annual physical or cancer screening, is covered in full under the Affordable Care Act. Those expenses and your premium are your expected annual medical costs.

But what if things don’t go as planned? Add your monthly premiums for the year and your out-of-pocket maximum. This amount is the maximum you’d spend in a year, and it can help you determine the plan that’s best for you.

Look carefully at each option within the range that fits your needs. Some may limit which hospital or doctors you can visit, so make sure that the facilities where you want to receive care, and the physicians you want to access, are included in the plan’s network.

Some health insurance plans do not cover all doctors and facilities at in-network rates, and that can get expensive.

Investigate your options carefully and select a plan that meets your financial needs and desired coverage levels and also provides full, in-network access to the doctors and hospitals that are important to you.