Picking a Healthcare Plan? 10 Smart Questions to Ask Your Insurance Agent

Knowing that your healthcare costs are covered for the year ahead can be a big relief. Thankfully, millions of Americans have access to health insurance through the Affordable Care Act (ACA). The ACA’s marketplace lays out your health insurance options so you can shop for a plan that best fits your needs. You can also learn more about available plans by calling (800) 827-9990.

These days, with more health plans than ever to choose from, how do you make sure you’re purchasing the right one?

That’s where licensed insurance agents come in. They’re licensed professionals who help you find a plan and complete the entire enrollment process — at no additional cost to you. Agents can assess your specific health needs and budget and make suggestions tailored to your situation.

“Agents know health plans inside and out,” says Tasha Riggs. She’s a licensed agent based in Westminster, Colorado. “As a broker, I have access to every single plan [in my area that I’m licensed for]. I find out what you need and what you want in a health plan. And we narrow it down with my knowledge to 2 or 3 plans that would fit that mold that you’re looking for.”

What might you want to ask your licensed insurance agent? Try these 10 questions.

A licensed insurance agent can help you sort out your options. Start online today, or call us at (800) 827-9990.

1. Why would I want an ACA plan?

The ACA is a law that provides rights and protections to health plan customers. And all ACA plans offer “essential” benefits, such as preventive care and mental health services.

“Every single health insurance policy that’s a major medical plan has to abide by that law,” says Riggs. So, when you buy a plan, you know you are getting comprehensive coverage.

You could also save money on your coverage because ACA plans offer subsidies to help you pay for your plan if you are eligible. Subsidies are monthly credits based on your income that lower the plan’s monthly premium costs. Many Americans with an ACA plan qualify for a subsidy.

2. How does shopping for an ACA plan work?

In most states, the ACA marketplace is run by the U.S. federal government. But some states might run their own.

Although plans are available through these federal and state marketplaces, you can also find them by shopping with a licensed insurance agent. For example, you can start here, or call a licensed agent at (800) 827-9990 today.

3. Will I qualify for a subsidy — and if so, how much?

That depends on your income and tax filing status. You may qualify for tax credits that lower your monthly premiums or provide savings on out-of-pocket costs. In fact, 4 out of 5 people shopping for an ACA plan can find plans that cost less than $10 a month after tax credits.

Whether you work with an insurance agent or apply online, you’ll be asked some basic questions about your income. You can use your most recent tax return as a guide. (Self-employed? You’ll need to make a good-faith guess based on your most recent earnings. A quick conversation with your accountant can help.)

4. What costs should I look at when shopping for an ACA plan?

To choose an ACA plan that fits your budget, you’ll have to factor in your monthly health plan bill (premium) and your potential medical costs. Your potential costs for care depend on the plan’s deductible, copays and coinsurance.

Your deductible is the amount you must pay before your plan pays the rest. A copay is a set fee for specific medical services, such as doctor visits or prescriptions. Coinsurance is when your insurance pays a percentage of your bill (and you pay the rest).

Another number to pay attention to? The maximum out-of-pocket limit, says Riggs. “Besides the premium, the max out-of-pocket is the next most important number to know,” she says. That is the maximum amount that you’ll have to pay in a year. After you reach that maximum, your plan covers 100% of your eligible medical costs for the rest of the year.

“That maximum tells you … the most you’re going to spend,” says Riggs. “That’s the magic number people need to know.” Just remember that this amount only includes care covered by your insurance plan.

5. How much healthcare coverage do I need?

How much healthcare coverage you need depends on your personal health needs and your budget. To compare coverage, start by comparing coverage based on the level of the plan. ACA plans are organized by “metal” levels:

• Bronze
• Silver
• Gold
• Platinum

Bronze plans generally have the lowest monthly cost, but they have higher out-of-pocket costs when you get care. Platinum plans, on the other hand, usually have the highest monthly cost, but lower out-of-pocket costs.

If you’re relatively healthy and don’t need much health care, a bronze or silver plan might be right for you. If you know you are going to have a lot of healthcare costs — say you have a chronic condition that requires a lot of treatment — a gold or platinum plan might make more sense for you.

Need help making up your mind? Call a licensed insurance agent at (800) 827-9990.

6. What if my medical needs change?

You’re not locked into your health plan for life. Every year, you’ll have a chance to shop around and change plans during Open Enrollment, which begins in November each year. At that time, you can sign up for a new plan that starts the following year.

If your healthcare needs change — maybe you were diagnosed with diabetes last year — you can switch to a plan that provides the coverage you need. Thanks to the ACA, an insurance company cannot turn you down if you have a preexisting condition.

Even if you don’t think you need to switch plans, it’s still a good idea to shop around and talk with your insurance agent each year.

“I ask everybody to call me every year so that we can go through their plan,” says Riggs. “Things change in this industry so fast. There might be some new benefit out there that you’re missing out on with a different company.”

Certain life events can also allow you to change plans outside of the Open Enrollment Period during what’s known as a Special Enrollment Period. You’ll have a window of time to enroll or change plans during a qualifying life event, such as:

• Getting married or divorced
• Having a child or adopting a child
• Losing your healthcare coverage
  • For example, if you lose a job that provided health insurance, or if you turn 26 and age out of your parent’s plan.
• Moving to a new state or ZIP code

If you think you qualify for a Special Enrollment Period, call a licensed insurance agent at (800) 827-9990. They can help you find a new health plan that fits your needs.

7. Will my favorite healthcare providers be covered?

Insurance companies put together networks of providers who agree to charge certain rates for their services. If you have a certain healthcare provider that you really want to stick with, you’ll want to make sure that they’re in the network of whatever plan you choose.

If you go out of network, you may wind up paying a whole lot more. Check the plan information with the insurance company or ask your agent. And if you have a preferred hospital, do the same.

8. What about my prescriptions?

Not every medication is covered by every plan. Just like you can check a plan’s provider network, you can also check their drug formulary. The formulary lists all the medications covered by the plan, along with their prices. You’ll want to make sure your prescriptions are covered and compare prices between plans.

9. Should I consider an HMO or PPO plan?

As you’re shopping for plans, you might notice that some are called PPOs and some are HMOs. What’s the difference?

With an HMO (Health Maintenance Organization) plan, you can only go to providers that are in that plan’s network. Most plans also require you to get a referral from your primary care provider to see any other type of provider. Those limitations help keep costs down and can provide you with better coordinated care.

With a PPO (Preferred Provider Organization) plan, you have a network of providers, but you also have the freedom to visit any healthcare provider you wish. But you’ll pay more when you go out of the network.

“Everybody thinks if they’re on a PPO plan, they can go to any doctor anywhere, anyplace. That’s technically true,” says Riggs. “But if that doctor is not in network, you’re going to pay much more. So even though you have a PPO, you usually don’t want to go out of network.”

Provider networks often mean you’re limited to providers in a certain location. If you travel a lot or split your time between 2 or more places, you might want to look for a plan that covers virtual care. Many plans offer telehealth services that let you get care anytime, anywhere. “You just pick up the phone, call a doctor, and get a prescription over the phone,” says Riggs.

And you don’t have to worry about emergency situations. “If you’re traveling and you have a medical emergency, by law, it has to be treated as if it was in network,” says Riggs. Your plan cannot charge you more for getting emergency care outside of the network.

10. Where do I turn if I need more help?

You can call your insurance agent with questions or problems. And their help doesn’t stop when you buy a plan.

“One of my commitments to my clients is that I provide white-glove service — not just in picking a plan, but after the plan too,” says Riggs. “I’ll help you with claims. I’ll help you understand a bill.”

Ready to get started? If you’re in the market for a new ACA plan, HealthMarkets can help you find health insurance at no additional cost to you. Start reviewing your options online today, or call (800) 827-9990 to speak with a licensed insurance agent.