Buying in the “individual market.” If you do not have access to employer-sponsored health insurance, you may buy your insurance directly from an insurance company or through an agent. However, Obamacare puts new requirements on all insurance sold in the individual market. Those requirements are outlined below under “Essential Benefits.”
While you may continue to buy your insurance through an agent or directly from an insurance company, you cannot receive tax credits or other federal discounts unless you buy insurance through the Marketplace website. That doesn’t mean you have to go-it-alone. If you have an insurance agent you trust, you can still sit down with him or her, compare plans and buy your insurance through the Marketplace website. We refer many first-time insurance buyers to agents or other trained professionals (known as navigators and certified application counselors) in Montana.
Buying insurance in the Marketplace.
The Marketplace is a federally built website where insurance policies sold by private insurance companies can be purchased. The Marketplace is the only source of federal tax credits or other insurance discounts.
It’s a website. It was built by the federal government. It attempts to do several things.
It’s a place where you can shop for and buy an insurance plan. All the plans sold in the Marketplace are sold by private insurance companies, each licensed to do business in Montana. All the plans – and their prices – have been analyzed by this office and satisfy all state and federal laws. The three companies selling policies through the Marketplace are the Montana Health CO-OP, PacificSource and Blue Cross Blue Shield. These companies also sell plans off the Marketplace. There are additional insurers and insurance products available outside the Marketplace.
The site tries to organize plans in a way ordinary people will understand. Insurance is complicated; it can be hard to know exactly what you’re buying and if it’s the insurance plan you and your family need. The plans sold in the Marketplace are organized by something called “actuarial value.” Actuarial value refers to the amount of your medical spending you pay vs. what your insurance company pays. The actuarial value of plans in the Marketplace is ranked, and each one is assigned a metal tier: platinum, gold, silver and bronze. Actuarial value requirements apply to health insurance products sold outside of the Marketplace too.
- Platinum: insurer pays 90%, you pay 10%
- Gold: insurer pays 80%, you pay 20%
- Silver: insurer pays 70%, you pay 30%
- Bronze: insurer pays 60%, you pay 40%
(Up to the maximum out-of-pocket, which cannot be higher than $6,350 for an individual or $12,700 for a family.)
This ranking refers only the plans actuarial value, not its coverage or provider network. All plans have the same essential health benefit package. Plans with a higher actuarial value will cost more every month, but they will cost you less at the doctor’s office when you pay your co-pay and you will pay a smaller portion of your total health care bill.
Some Montanans will also be able to buy “catastrophic” plans, which have a much lower actuarial value bronze plan. To be eligible for a catastrophic plan, you must be under age 30 or be exempted from the individual mandate because you can’t find affordable coverage — even after the tax credits have been applied.
Montanans access the Montana Federal Health Insurance Marketplace at www.healthcare.gov. There are four ways to apply for Marketplace coverage – by paper application, online, by calling 1-800-318-2596, or by contacting a trained professional near you in Montana. You can find a list of them here. Working with a pro is often the best way to buy insurance through the Marketplace. Using the online application format is usually the best and quickest way to apply.
Over 80 percent of Montanans who have bought insurance on the Marketplace have been eligible for tax credits that will bring down the cost of their health insurance. We encourage Montanans to shop in the Marketplace to see if they can find an insurance policy and save money every month.
Obamacare sets new standards for what insurance companies must cover. These standards apply to individual and small employer group coverage policies sold both inside and outside the Marketplace. Many of these new federal requirements were already in Montana law. If you have insurance now, your policy already covers most of these things, although a few are new. No matter which policy you purchase in the Marketplace — even the least expensive one — you will get coverage in the following ten areas. These areas are called essential health benefits and every plan in the individual and small group markets must cover them:
- Hospital visits and surgery.
- Doctor’s office visits.
- Prescription drugs.
- Maternity and newborn services.
- Mental health and chemical dependency services.
- Lab work and imaging.
- Rehabilitation services and services intended for skill acquisition, like speech therapy for a child who is currently non-verbal.
- Dental and vision care for children.
- Preventative care and management of chronic diseases like diabetes.
- Emergency services.
In addition, all plans sold in the Marketplace include maximum out-of-pocket caps. That means there is a maximum amount your insurance company can make you pay, even if your health care costs are very high. For individuals, the cap is set at $6,350. For families, it is set at $12,700, even if you buy a bronze plan.
Obamacare also outlaws the practice of refusing to sell insurance to those with “pre-existing conditions” or charging those people more. The law also outlaws insurance plan exclusions, such as refusing to cover a person’s knee if they’ve had knee problems. If you have survived illness or injury or have any other kind of pre-existing condition, you can buy insurance inside or outside the Marketplace. You cannot be turned down and you will not be charged more.
The first enrollment period began October 1, 2013 and ended March 31, 2014. All plans purchased in the Marketplace before December 23, 2013 have an effective date of January 1, 2014. For coverage starting in 2015, the open enrollment is November 15, 2014 – February 15, 2015.
Outside of open enrollment, Montanans will not be able to buy individual insurance unless they have a “life event,” which starts a special enrollment period. Life events include, but are not limited to:
- Losing job-based insurance coverage;
- Marriage or divorce;
- Birth or adoption; and
- Death of a spouse
Members of Montana’s federally-recognized tribes will be able to purchase health insurance during special, monthly enrollment periods.
So, now you understand the Marketplace and are ready to shop for an insurance plan, right? We’ve put everything right here that you will need to look at plans sold in Montana, compare their prices and estimate the kind of federal tax credit you may be eligible for to bring down your monthly costs.
Buying the right plan can be tricky. Download our “Things to Consider When Choosing A Plan” checklist to help guide the process.
Three insurance companies — Blue Cross Blue Shield, Montana Health CO-OP, and PacificSource — are offering plans on the Marketplace. Compare the plans by tier level, deductible, out-of-pocket max, coinsurance and copay here.
You will also want to know exactly what each of the plans cover, which physicians and health care facilities are in their provider networks, etc. All of that information is in a document called a “Statement of Benefits and Coverage.” By law, each insurance plan must have one. You’ll find that information on the insurance company’s website — Blue Cross Blue Shield, PacificSource, Montana Health CO-OP. If you need help with term definitions, visit our Health Insurance 101 page.
Now how much is all this going to cost you? We broke the prices out for you by company. Click on the the company logo below for the list of all their product prices. The prices listed are for one person in an age bracket. Let’s say you are a family of four: A 35-year-old, a 40-year-old, and two kids, aged 4 and 7. To find the total price for the family, you take the price listed under your plan for the age of each family member. All children under age 20 are the same price. Then, you add all the premiums together for your family cost. However, you cannot be charged for more than three children under 20.
Download PDFs of Insurance Rates By Company
There is a lot of flexibility in the kind of policy you can buy. If you only need coverage for a child – even an infant – you can buy just that. Or if the children are covered by Healthy Montana Kids, you can buy plans just for Mom and Dad.
Price is only one part of the equation in figuring exactly what you might expect to pay each month in premium. Obamacare created federal tax credits to bring down the monthly premium cost. These credits are paid directly to your insurance company every month. Eligibility is based on income.
Enter your income, family size, and age into this calculator to get an estimate of your eligibility for subsidies and how much you could spend on health insurance. Please remember this is only an estimate. Actual amount may be higher or lower.