Not having health insurance can take a toll on your health – and your wallet. Without it, an accident, unexpected illness or even a relatively simple injury can cost thousands of dollars out of pocket.
Cost aside, research shows people with insurance are more likely to have regular doctor visits and receive care when they need it. Early detection of illness and other health conditions is critical for the 6 in 10 Americans who live with at least one chronic disease.
Still, some 28 million people in the U.S. lacked health insurance coverage in 2020. If you don’t have insurance through your employer, you can choose a plan through the Health Insurance Marketplace.
Who qualifies?
U.S. citizens who don’t have insurance through a job, and those who cannot get Medicaid or Medicare, can choose a marketplace. Permanent residents and certain other immigrants also qualify.
Mark these dates on your calendar:
- Open Enrollment begins Nov. 1, 2022.
- Open Enrollment ends Jan. 15, 2023.
- Enroll by Dec. 15 for coverage effective Jan. 1, 2023.
- Enroll between Dec. 16 and Jan. 15 for coverage effective February 1, 2023.
What do these plans cover?
- Preexisting conditions: No insurance plan can reject you, charge you more or refuse to pay for essential health benefits for any condition you had before your coverage started, including disabilities, chronic health conditions and pregnancy.
- Essential health benefits: These include prescription drugs, lab costs, outpatient care, emergency services such as hospitalization, treatment for mental health and substance abuse disorders, rehabilitative services, devices to help people with injuries, preventive and wellness services and chronic condition management and pediatric services, including oral and vision care. Birth control and breastfeeding coverage also are offered with every plan.
- Preventive care: Preventive services, such as shots and screening tests, are covered by most health plans at no cost to you. It’s important to note these services are free only when delivered by a doctor or provider who is in your plan’s network.
Can I get financial assistance?
Millions of people qualify for a premium tax credit that lowers their monthly payment, also known as a premium. More than 430,000 North Carolinians qualified in 2020.
Eligibility depends on income and household size. This includes people with an annual income up to about $51,000 or $106,000 for a family of four.
In 2021, the average monthly premium in North Carolina was $633, but those who qualified for a premium tax credit paid an average monthly cost of $125 – about $6,000 in annual savings.
Pro tip: If your income rises during the year you also should report it, so your monthly premium subsidy is reduced, helping you avoid a potentially hefty tax bill come April.
Find out if your estimated income is in the range to qualify for a premium tax credit.
Deductibles, copays and more
Short-term plans (or association plans) are not equivalent to the health insurance plans on the marketplace. They may look less expensive, but the low monthly premium often comes with a high deductible that will actually cost you more in the long run.
A deductible is the amount of money you must pay for health care out of your own pocket before your insurance plan starts covering some of the cost. For example, if your deductible is $1,200, that’s the amount you’ll pay out of your own pocket for health services before your insurance starts covering some services.
Another expense to watch for is the amount of your copayment, or copay. That’s a flat fee that patients are expected to cover every time they use a health care service. For example, even with insurance you might be expected to pay $25 every time you see a doctor or pick up a prescription.
It’s important to think about both kinds of costs when shopping for a plan. This downloadable guide can help.
Why the cheapest plan may not be the best option
Comparison shopping is straightforward on the Health Insurance Marketplace, because at each of the four levels of coverage — bronze, silver, gold and platinum — benefits are uniform from insurer to insurer. Generally, plans in categories with lower premiums pay less of your total costs. Categories with higher premiums usually pay more.
The lowest premium, a bronze plan, is not necessarily the wisest — or cheapest — choice. Higher deductibles and coinsurance rates could cost more than a higher premium plan if you become ill or have an accident. Coinsurance is the portion you pay for health services once you’ve met your deductible. For example, after your deductible is met, your coinsurance rate could be 20%.
Also, pay close to attention to plan and network types. Some plan types allow you to use almost any doctor or health care facility. Others limit your choices or charge you more if you use providers outside their network.
Need help choosing a plan? You can call the Health Insurance Marketplace help line at 800-318-2596.
How do I sign up?
Healthcare.gov is the best place to go for up-to-date plans covered under the Affordable Care Act. Insurers in the marketplace can't turn people down or charge them more based on their medical history and preexisting conditions.
Be cautious when purchasing plans not sold on the marketplace. Some plans may not cover preexisting conditions or have a network of doctors and other providers. What does that mean? If your health plan doesn’t have a contract with your doctor or facility, they’re considered out-of-network and can charge you full price. And that’s usually much higher than an in-network rate.
Will I have to switch doctors?
No. Avoid the hassle of finding a new doctor by checking to see if they will remain in-network. It can save you time – and money.
When a health plan doesn’t have a contract with your doctor or facility, they’re considered out-of-network and can charge you full price. And it’s usually much higher than an in-network discounted rate.
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