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3: Analyze Your Circumstances

What are your Coverage Options? Know Where You Fit

Have You Served in the Military?
Veterans and active military have additional benefits to consider including Tricare, the health care program for over 9 million uniformed service members, retirees and their families.


Click on each category to learn more about who typically uses its plan offerings, the kinds of plans included, usual costs and how to get more information. Plans in the Affordable Care Act (ACA) Marketplace must meet minimum essential coverage (MEC) guidelines. Be aware of essential services in whichever plan you choose.

  • Who: Almost 64 percent of Americans buy their own insurance or are covered through employer-based health insurance.
  • What: Plans included in this category are:
    • Conventional (fee-for-service) plans where you can choose any provider.
    • Preferred provider organization (PPO) plans where you pay less if you stay in-network for services, but you can go out-of-network for higher costs.
    • Health maintenance organization (HMO) plans where you receive comprehensive services within a provider organization.
    • Point-of-service (POS) plans which are similar to HMOs but allow you to go out of the organization for services if you pay the additional costs.
    • Medigap supplemental plans that Medicare recipients often purchase to cover deductibles, copayments and other expenses not covered by Medicare.
    • High-deductible health plans (HDHP) come with higher deductibles but usually lower your monthly premium. In aggregate deductible plans, family deductibles must often be met before individual costs are covered. These plans can often be combined with a health savings account (HSA), so you pay for medical costs with pretax money.
  • Costs: Your costs will vary depending on negotiated rates for premiums, copays and deductibles. Continuing your health insurance (for up to 18 months) after leaving a job under COBRA is more expensive because you are paying a full premium.
  • Get More Information: If you are using an employer’s insurance, contact your human resource department and refer to your insurance policy summary. When shopping for your own coverage, use this map from the National Association of Insurance Commissioners (NAIC) to check out your state’s Division of Insurance, learn about regulations and verify insurance broker licenses.

    If your employer offers a plan, you may still want to check out the ACA health exchange (marketplace). The government lays out affordability qualifications for health plans to help you compare.
  • Who: About 12 million Americans are enrolled in ACA health exchanges (marketplaces). If you are self-employed, unemployed, work for a small business or if your employer does not offer health insurance, you probably bought coverage through your state ACA health exchange.
  • What: Plans included in this category are listed in “metal” categories.
    • Bronze in which the insurance company pays an estimated 60 percent of costs; you pay 40 percent.
    • Silver in which the insurance company pays an estimated 70 percent of costs; you pay 30 percent.
    • Gold in which the insurance company pays an estimated 80 percent of costs; you pay 20 percent.
    • Platinum in which the insurance company pays an estimated 90 percent of costs; you pay 10 percent.

      Higher premium categories (gold and platinum) cover more of your total costs; lower premium categories (bronze and silver) cover less. A catastrophic plan is available for those under 30 or who meet hardship exemption criteria. Catastrophic plans feature low premiums but much higher deductibles. You must meet your deductibles (current deductible is $7,900), then the insurance pays for all your medical costs.
  • Costs: Your premiums, deductibles and copayments vary depending on the plan category you choose. Depending on your income, you may qualify for premium tax creditsA tax credit based on income and household information that can be used to lower your monthly insurance premium. or Cost Sharing Reductions (CSRs)A discount that lowers what you pay for deductibles, copays, coinsurance and out-of-pocket maximum in the silver plan. You must enroll in a silver plan to get the extra savings.. If you choose a catastrophic plan, you cannot use tax credits for your premiums; the current (2019) deductible is $7,900.
  • Get More Information: Access health exchange information, see if you qualify for subsidies and enroll at Health care.gov (which will direct you to your state’s ACA exchange). If you work for a small business, someone familiar with human resources may be able to help. You can enlist a reputable broker through the exchange. Find one who works with all the insurance companies in your area and offers unbiased advice. Brokers are usually paid by the insurance company, so there is no charge to you for their help.
  • Who: If you are 65 or older, have certain disabilities or end-stage renal disease, you may enroll in Medicare.
  • What: Medicare is a federal program divided into “parts” that cover different aspects of health care:
    • Part A covers inpatient hospital care, critical access hospitals and skilled nursing facilities (rehabilitation — not long-term care). Most Medicare recipients receive this coverage without a premium, since they paid for it while working.
    • Part B, for a monthly premium, provides insurance for doctors’ services and outpatient care including physical/occupational therapy and home health care.
    • Part D provides prescription drug coverage for a monthly premium.
    • Medicare Advantage (sometimes called Part C) is offered by private insurance companies approved by Medicare.
  • Costs: Medicare costs vary depending on how long you have paid into the program, what plans you choose and whether you use a Medicare Advantage program or standard Medicare.
  • Get More Information: Use Medicare.gov to sign up for Medicare and find out more about coverages and costs, including Medigap and Medicare Advantage plans.
  • Who: In 2018, just over 73 million individuals, including families, children, pregnant women, the elderly, and people receiving Supplemental Security Income (SSI) were covered by Medicaid and the Children’s Health Insurance Program (CHIP).
  • What: Medicaid and CHIP are joint federal and state programs. Federal guidelines dictate what services states are required to offer, but each state may offer additional services. Contact your state for more information about qualifications and services.
  • Costs: States may charge premiums and establish costs for copayments, deductibles and similar charges depending on your income level and needs. Most vulnerable groups, such as women and children, are covered for free.
  • Get More Information: Use the Benefit Finder at Benefits.gov to identify federal benefits for which you or family members might qualify, including Medicaid and CHIP.

Case Study: Choosing Coverage

Choosing the right coverage depends on a lot of circumstances. You may have to research several of them to know what is best for your needs, as this case study demonstrates.

Jillian is 37, single and has a 13-year old son and an 11-year old daughter. Except for minor colds and illnesses, Jillian and her children are healthy. She works two part-time jobs, but neither employer offers medical coverage. Which options can Jillian explore to find health care plans for her and her children? Click on each option below to see how it may apply.

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