Navigator Guide FAQs of the Week: Comparing Plans

Open Enrollment is drawing to a close; in most states, consumers only have until January 15 to sign up for a 2023 marketplace plan, absent a limited set of circumstances that may arise throughout the year. To help with last-minute shopping for health insurance, we’re highlighting some of the FAQs on CHIR’s Navigator Resource Guide about comparing plan options.

What is the difference between a premium and a deductible? If I want to save the most money possible, should I just pick a plan with the lowest premium? 

A premium is the amount you pay for your health insurance every month. A deductible is the amount you pay for covered health care services before your health insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you meet your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.

Before enrolling in a plan, you should check its provider network for your preferred doctors or facilities, and check the formulary for your medications. Often, if you receive services from an out-of-network provider, those charges will not be counted towards your deductible.

You should also consider how often you use health care services and how much you would be able to pay out of pocket amidst an expensive unexpected emergency. It is important to find a reasonable balance between an affordable premium and also a deductible that would be manageable to pay out of pocket throughout the year or all at once in the instance of an unexpected medical event. A plan with the lowest premium may not necessarily be the most financially beneficial plan to choose if you have a medical condition that requires prescription drugs or visits with your provider throughout the year.

I notice marketplace plans are labeled “bronze,” “silver,” “gold,” and “platinum.” What does that mean?

Plans in the marketplace are separated into categories — bronze, silver, gold, or platinum — based on the amount of cost-sharing they require. Cost-sharing refers to out-of-pocket costs like deductibles, co-pays and coinsurance under a health plan. For most covered services, you will have to pay (or share) some of the cost, at least until you reach the annual out-of-pocket limit on cost-sharing. The exception is for preventive health services, which health plans must cover entirely.

In the marketplace, bronze plans will generally have the highest deductibles and other cost-sharing. Silver plans will require somewhat lower cost-sharing, but this may not always be the case. If you are deciding between a bronze and silver plan, you will want to determine what the cost-sharing amounts are for the services you would use under each plan. Gold plans will have even lower cost-sharing. Platinum plans will have the lowest deductibles, co-pays and other cost-sharing. Keep in mind, however, that if you qualify for cost-sharing reductions, you must enroll in a silver plan to obtain cost-sharing reductions that lower your out-of-pocket costs. (45 C.F.R. § 156.130; 45 C.F.R. § 147.130; 45 C.F.R. § 156.140).

I am interested in making sure my plan includes a provider who is culturally competent. Do provider networks list the race/ethnicity of the provider or their experience with certain communities?

Provider directories do not have to include information about the race/ethnicity of the provider or specific expertise in working with particular communities. Some provider networks, however, voluntarily include this information. If you are interested in finding providers in your network who are from or who have experience working with certain communities, looking to national and state provider networks hosted by professional medical associations may be helpful (for example, Gay and Lesbian Medical Association, Black Doctor.org, and Trans Health).

How can I find out if a health plan covers the prescription drugs that I take?

Health plans in the marketplace must include a link to their prescription drug “formulary” (a list of covered drugs) with other on-line information about prescription drug coverage such as tiering structures and whether any restrictions exist to accessing covered drugs. The formulary should be easily accessible, meaning that it can be viewed on the health plan’s public web site through a clearly identifiable link or tab without creating an account or entering a policy number. The health plan must provide the formulary for the health plan and not a general list for the insurer. If you don’t find your drug on the formulary but your doctor says it’s medically necessary for you to take that specific drug, you can apply for an exception to the plan formulary. A prescription look up tool is also available on HealthCare.gov for consumers to determine whether or not a health plan covers a prescription drug. (45 C.F.R. § 156.122).

As the open enrollment season wraps up, stay tuned for a few more weekly blogs highlighting answers to questions about signing up for and using coverage. For more FAQs, state-specific enrollment information, and other enrollment resources, check out CHIR’s Navigator Resource Guide.