Under the ACA, all citizens of Florida are required to have health insurance. If you aren’t covered by your job, then you’ll need to purchase an Individual Health Plan.
Types of Plans Available
Under the Affordable Care Act (ACA), the four basic types of health insurance plans haven’t changed. There are private insurance companies that sell HMOs, PPOs, EPO’s, and POS plans “on” the marketplace and “off” the marketplace.
In Florida we do not have our own insurance exchange, like some other states, we are required to use the federal government website called Healthcare.gov when a person is interested in applying for a premium tax credit (subsidy). The price tiers, coverage options, and eligibility rules have changed from pre-ACA.
When you compare options, it’s important to understand how health insurance plans are structured and how they have changed due to the ACA. Speaking with a licensed insurance agent or a trained ACA health consultant is the best way to understand all of your options.
Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs)
HMOs and EPOs may limit coverage to providers inside their networks. A network is a list of doctors, hospitals, and other healthcare providers that provide medical care to members of a specific health plan. If you use a doctor or facility that isn’t in the HMO’s network, you may have to pay the full cost of the services provided or be responsible for the remaining balance.
HMO members usually have a primary care doctor and must get referrals to see specialists. This is generally not true for EPOs, which works more like a PPO which we will discuss next.
Preferred Provider Organizations (PPOs) and Point-of-Service plans (POS)
These insurance plans give you a choice of getting care within our State or out of State using a larger provider network. With PPO or POS plans, you may use out-of-state network providers and facilities. If you have a PPO plan, you can visit any doctor without a referral, including specialists.
If you have a POS plan, you can visit any in-network provider without a referral, but you’ll need one to visit a provider out-of-network.
High Deductible Health Plan (HDHP)
High Deductible Health Plans typically feature lower premiums and higher deductibles than traditional insurance plans. The IRS gives rules to define the HDHPs as health insurance plans with a minimum deductible of $1,300 per year for individual coverage and $2,600 for family coverage and the Out Of Pocket Max (OOPM) that cannot be more than $6,550 for a person and $13,100 for a family assuming you are staying in-network.
If you have an HDHP, you can use a health savings account or a health reimbursement arrangement to pay for qualified out-of-pocket medical costs. This can lower the amount of federal tax you owe. You can put pre-income tax dollars into this special health savings account (HSA) and only use that money for qualified medical expenses as long as you also buy an HSA qualified health insurance plan.
Catastrophic Health Insurance Plan
A catastrophic health insurance plan covers essential health benefits and also has a very high deductible. This means it provides a kind of “safety net” coverage in case you have an accident or serious illness. Catastrophic plans usually do not provide coverage for services like prescription drugs or shots. Premiums for catastrophic plans may be lower than traditional health insurance plans, but deductibles are usually much higher. This means you must pay thousands of dollars out-of-pocket before full coverage kicks in.
In the Healthcare.gov Marketplace, catastrophic plans are available only to people under 30 and to some low-income people who are exempt from paying the fee because other insurance is considered unaffordable or because they have received “hardship exemptions”.
Marketplace catastrophic plans cover 3 annual primary care visits and preventive services at no cost. After the deductible is met, they cover the same set of essential health benefits that other Marketplace plans offer. People with catastrophic plans are not eligible for lower costs on their monthly premiums or out-of-pocket costs.
Health plans today are custom-quoted to you by private insurers, just like before the ACA. Prices are NOT the same for everyone. That’s why you should speak with a licensed insurance agent or an ACA consultant before buying health insurance. There is no added expense for this assistance, no fees are charged, a free service to you that the health insurance companies provide for its potential customers or existing members.
Individual Health Plans are available in four “Metal” Categories: Bronze (least expensive plans), Silver, Gold, and Platinum (most expensive level). The categories differ in terms of their deductible and coverage options.
The price you pay for your Individual Health Insurance Plan is determined by several factors and your agent will ask you for all the needed information. Be prepared to provide legal name, address and zip code, date of birth, social security number, and your smoking status to the health insurance agent.