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With so many terms and health insurance plan details to consider, it’s no wonder why so many Americans get confused when it’s time to enroll. And for many consumers, who have relied on employer-sponsored health insurance for so long, the thought of even venturing onto the ACA marketplace to find a new plan can be intimidating. But it doesn’t have to be challenging, and half the battle is understanding the terms and nuances providers use to describe their plans. Today, we’ll offer a Part 1 segment of health insurance term definitions. And we’ll outline how having this term knowledge can help you choose the best plan for you and your family.

Understanding Health Insurance Eligibility Terms

You know what the actual word “eligibility” means. But what may still be cloudy for you is understanding the various terms associated with eligibility and the marketplace. There are different health insurance plans available, but many other benefits can be rooted in your eligibility.

Eligibility for Marketplace Enrollment Terms
To be eligible for a marketplace health insurance plan, you won’t have an employer group plan at your disposal. Many companies are venturing into HRA offerings, which would mean you are required to enroll in a marketplace plan. Without an affordable health insurance option available in any other circumstance, you can rest assured knowing you are eligible to begin browsing the marketplace to find a provider and plan.

Eligibility for Premium Tax Credits
You might start browsing the various plans via the marketplace and immediately notice how lofty some of those monthly insurance premiums are for coverage. Before you make an enrollment decision, you should first explore your eligibility for the premium tax credits. These credits are based on your household headcount and income levels. If you qualify, the credits can be applied directly to the monthly premiums of the health insurance plan you select. In many cases, it provides a drastic offset in premium cost.

Eligibility for a Special Enrollment Period
You may not have been eligible for marketplace insurance plans last December or during the annual open enrollment period. But if you have sustained a job loss, got married, moved to a new state, or had a child, you qualify for a special enrollment period. These SEPs allow for a new window of eligible enrollment via the marketplace and are based on providing you’ve had a qualifying life event. Any of these scenarios can translate to new and even more affordable coverage outside of the traditional enrollment window. But it’s important to know the president has authorized a nationwide special enrollment period now through May 15, 2021. So even if you missed enrollment and don’t qualify, you’re able to explore your marketplace options right now.

Health Insurance Terms By the Acronyms

Some of the most confusing health insurance coverage terms of all, especially those related to enrollment, include the various acronyms used to describe the plan types. To help you decide which plan is best, you’ll want to consider these definitions and plan features.

Preferred Provider Organization aka the PPO
The PPO is fairly common, and you may already be familiar with its parameters since many employers use PPO group plans. But you’ll have marketplace enrollment options for PPO plans, as well. It’s a great choice should your healthcare providers be considered in-network. Any providers not considered a preferred provider will likely translate to increased out-of-pocket expenses for you, however.

Health Maintenance Organization aka the HMO
HMOs are common, too, and you’ve probably at least heard of this kind of health insurance structure. Similar to the PPO, in-network providers offer the most cost-effective coverage. But the HMO is generally the least flexible of all marketplace plan types. Any doctor visits considered outside the network may be your responsibility in total.

Consolidated Omnibus Budget Reconciliation Act aka COBRA Insurance
COBRA insurance coverage is an option you might have should you need to keep insurance after losing employment. This may be available to you if you’re considering new health insurance because of a job loss. But because COBRA usually requires the individual to pay 100% of the premiums, it can be incredibly expensive, especially if you’re looking for coverage without employment.

Enrollment Terms as You Browse for Health Insurance

You’ll see that you can sort health insurance plans on the marketplace. One distinguishing factor is the metal tiers. Much like the Olympic podium, each level of health insurance offers a bump in plan dynamics. But before you enroll, you’ll want to understand the terms of bronze, silver, and gold plans. All tiered plans provide preventive care coverage and other essential health benefits free of charge. And the ranking only reflects differences in pricing. These classifications in no way impact the quality of care.

Bronze & Silver Plans
These plans are considered to be the least expensive of health insurance plans. They’re popular for individuals and families who are relatively healthy and not expecting concerns. The monthly premiums are cheap, but the coinsurance and copays for doctor visits are generally high. Bronze plans typically offer a 60/40 split of costs, while Silver plans provide closer to a 70/30 split of healthcare expenses.

Gold Plans
Gold plans tend to be the moderate plans. The monthly premiums will be higher than bronze or silver plans. But these health insurance providers will offer less expensive copays and smaller deductibles. These plans offer an average range of 80/20 coverage of healthcare expenses.

Platinum Plans
While you might assume the platinum plans are the best, there are still some nuances to consider about the coverage. You’ll be paying a high monthly premium but can expect 90% or more of your medical bills to be covered. Know that you will still be responsible for meeting a deductible.

If you’re facing an enrollment process and still feel a little intimidated by the marketplace full of health insurance options, browse with W3LL. In addition to understanding these various health insurance enrollment terms, having a free service partner to help you navigate can simplify everything. Answering a few questions about your situation will allow us to sort through all the available plans and present those options that meet your needs. We can also help you determine premium tax credit eligibility. Contact us and get started today!


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