Navigating the Marketplace, Georgia Access or even health insurance alone can be like trying to understand a foreign language. But fear not! This guide is your Rosetta Stone to the world of insurance terms you’ll run into during the quoting process for Marketplace insurance policies.
Terms to Note Before Starting the Quoting Process
Firstly, you may be wondering – What are Marketplace plans?? If you’re unfamiliar with this term, here’s a simple breakdown what it is, where and when you can get it, and who it’s for:
What & Where?
“Marketplace insurance” is associated with the Affordable Care Act (ACA) which created an online space called the marketplace or “exchanges” where you can compare and shop for health insurance plans offered by private companies. For this reason, you may hear Marketplace plans referred to as “ACA” or “On-Exchange” plans. In essence, the marketplace is a one-stop-shop for comparing different health insurance policies and finding what fits your budget and coverage needs in your area.
For Georgia residents, Georgia Access will replace the Marketplace for 2025. Contact us for help with this!
For whom?
Almost anyone living in the U.S., who is a U.S. citizen or national, and not incarcerated can apply for these plans under certain circumstances. These plans are available to individuals and families who don’t have access to employer-based insurance or don’t qualify for government programs like Medicare or Medicaid. If you meet certain income requirements, you might be eligible for discounts on your plan. In essence, the marketplace is a one-stop-shop for comparing different health insurance policies and finding what fits your budget and coverage needs in your area.
When?
It’s vital for us to break down some lingo that revolves around another important question: When can you apply for Marketplace insurance? It’s no question that someone in the US is always seeking insurance no matter what time of year it is. However, not everyone knows that there’s actually a designated period of the year when everyone can sign up for health insurance or make changes to their existing coverage. This period is known as the annual Open Enrollment Period. This is the “open house” for everybody to freely enroll in a new health plan, renew a current plan, or switch plans. This period typically runs from November 1 to December 15 in most states for a plan that will start January 1st of the following year (though states with their own marketplaces may have slightly different dates for open enrollment).
It’s always a good idea to check the specific dates for your state (if you’re outside of GA) or consult with your employer if you have insurance through your job, as they may have their own open enrollment periods as well.
Exceptions Outside of Open Enrollment
Missed Open Enrollment? There’s still hope! You can buy coverage at other times of the year if you have something known as a qualifying life event (QLE) which is an event or occurrence that sparks a special enrollment period (SEP) of 60 days during any time of the year for you to enroll in a Marketplace plan outside of open enrollment.
Examples of QLEs may include:
o Losing your health insurance coverage.
o Having a baby or adopting a child.
o Getting married.
o Getting divorced or separated.
o Death of a spouse or dependent.
o Moving to a new ZIP code.
o Income changes that make you eligible for ACA marketplace premium tax credits.
o Losing Medicaid eligibility.
o Aging out of your parent’s health insurance when you turn 26.
To get an exhaustive list of QLEs that make you eligible for a SEP, take a look at this article from the Marketplace that delves deeper into a list of life changes and who is eligible for an SEP.
Terms You’ll Notice During the Quoting Process
When getting a quote for Marketplace plans, you’ll notice that the Marketplace (or an agent assisting you with the quote) will need specific information from you to generate the plans that are available to you and your family. Most of it is pretty straightforward, such as your zip code, your birthday, etc. However, there’s some information required that can be easy to misinterpret. This would especially include two variables known as your total number of “Household members” as well as your “Estimated Annual Household Income”.
Many people immediately believe “household members” to simply mean the number of people living in their physical household, and the “household income” to in turn be the total amount of income generated from that group of people. However, that’s not exactly the case. In the case of getting a quote for Marketplace insurance, these terms refer to your “tax household’s” members and income. Let’s break each part down simply:
The total number of members in your tax household (also referred to as “household members” in the quoting process) is simply the total number of people you file taxes with and/or claim on your taxes. This typically includes:
- You (the tax filer)
- Your spouse (if you’re legally married and filing jointly)
- Your dependents (such as children or other relatives you claim on your taxes)
This point is vital to understanding who to include in as well as who NOT to include in total, as it can significantly change the results of your quote. Understanding this term then distinguishes individuals that may live in your physical household but are not actually part of your tax household. These people include:
- Roommates: People you live with but do not claim as dependents.
- Legally separated or divorced spouses: Even if you live together, they are not part of your tax household.
- Non-dependent children or other relatives: If you do not claim them as dependents on your tax return.
- Unmarried domestic partners (Unless you have a child together or you claim them as a tax dependent)
Understanding this term will now help us better understand what the Marketplace is asking for when providing the estimated Household Income for a specified year. Again, this is the total income for your tax household. This is your best guess of what your combined gross income (before taxes) of you (and anyone you file taxes with or claim on your taxes) will be for the year you’re seeking coverage. This is used to determine your eligibility for savings on Marketplace plans. Which comes in the form of something known as a subsidy.
Households with incomes between 100-400% of the federal poverty level receive savings known as “subsidies to lower health care costs. A subsidy (also known as a “premium tax credit”) on the Marketplace is financial assistance provided to help lower the monthly premium of your health insurance. A monthly premium is the amount you pay for your insurance policy every month. Think of it as a subscription fee for your health coverage. So, the Premium tax credit/subsidy would essentially be a discount to you on the normal cost of a plan. The Marketplace evaluates whether you’re eligible for these savings based on your estimated household income and family size, and it’s applied directly to your insurance premium to make it more affordable.
TERMS TO KNOW WHEN COMPARING DIFFERENT PLANS
Now, once you’ve provided all the information needed for the quote, you’ll then have a variety of plans available to choose from. This stage of the quoting process comes with another set of terms that will help you and the agent compare those plans to find the best options for you.
Firstly, it’s a no-brainer that the first thing most people are going to look at is each plan’s monthly premium (monthly cost) and what range is affordable for them. That’s always a great place to start! However, the next type of costs to consider when comparing plans is the Out-of-Pocket Costs. These are expenses for medical care/services that you must pay yourself because they’re not covered by your insurance plan. Keep in mind that the term “Out-of-pocket costs” is actually an umbrella term for multiple types of costs that often get confused with each other, so we’ll list and define them below:
Deductibles: A deductible is a set dollar amount you pay for covered healthcare services before your insurance plan starts to pay toward them. Please note that some services within a certain plan may require you to pay full price or most of the cost for specific services before you meet this deductible. Then, upon meeting the deductible, the insurance will cover more or all of the costs of those specified services. However, there are some services that you’ll pay a specific cost for (or no cost at all) regardless of whether you’ve met that deductible or not. These are your copays.
Copayments (Copays): A copayment is a set amount you pay for a specific healthcare service, like a doctor’s visit or a prescription for example. You might find a plan that gives you an out-of-pocket cost of $20 for a visit to your primary care physician regardless of what your deductible is or if you’ve met it. You usually pay the copay at the time you receive the service.
Coinsurance: Often confused with copayments, this is a percentage of the cost of a covered healthcare service that you pay after you’ve met your deductible. In other words, it’s your share of the costs of a covered service. It’s like going dutch on a meal; you pay 20% for a $100 bill ($20), and your insurance covers the remaining 80% ($80), So in this case, your out-of pocket cost for the service would be $20.
Out-of-Pocket Maximum: This is the most you will have to pay for covered services in a plan year. After spending this amount on all combined out-of-pocket cost (such as your deductible, coinsurance, and copayments, etc.) your health plan will pay 100% of the costs of covered benefits afterward. (It’s good to note here that coinsurance only applies to you until you reach this out-of-pocket maximum limit.)
After looking at all the given costs in each area for a plan, it really boils down to what is affordable for you (now and in certain hypothetical situations like emergencies) and what type of coverage/costs fit your specific health needs.
With so many terms to consider it’s very easy to confuse mix them up, especially when the language of insurance isn’t exactly something the world teaches us to be fluent in to begin with! That’s why having the help of an attentive and knowledgeable agent who can translate the gray areas for you is what we’re here to do! To make Marketplace shopping bearable and so much smoother. Everyone will have varying preferences on what they’re willing to pay for and how much coverage they’d like to have in all kinds of scenarios. As a result, understanding the jargon can save you time, money, and stress in the process. And with this guide, you’ll be fluent in insurance lingo in no time!
