Health Insurance Buyer’s Guide

There are other ways to have health insurance coverage. One big way is through your job. Federal law requires all employer-sponsored plans to meet minimum standards of quality and affordability. Your employer will know if their insurance plan meets these requirements. If it doesn’t, you can buy insurance on your own through healthcare.gov and receive a tax credit to lower your costs, if you qualify.

If you don’t have insurance through work — and you don’t have other kinds of coverage — you will need to buy it on your own. There are lots of ways to buy insurance and lots of people who can help. Depending on your income and the number of people in your family, you can receive financial assistance to lower your costs.

All insurance sold in Montana must meet certain basic requirements. We spelled out all the legal requirements for health insurance on our Law page.

All insurance must also be organized in a way that makes it easier for you to see how much it will cost you every month — and throughout the year. All plans must be ranked by the portion of your medical costs the company pays: Platinum, Gold, Silver, Bronze. Platinum plans pay the greatest portion, but cost the most every month. Bronze plans pay the least portion, but also cost the least.

Regardless of the plan you buy, there are caps on the amount of money you can be asked to pay out-of-pocket each year. An individual, for 2021, will not pay more than $8,550 a year out-of-pocket; a family will not pay more than $17,100. This doesn’t mean you will always pay that much out-of-pocket. Many plans sold in Montana have much lower caps built into them.

These rankings give some information about your insurance plan, but they cannot tell you how much you will actually end up paying. We recommend looking at the details of the plans side-by-side. We’ve done that work for you under Digging Into the Details.

You can buy health insurance:

• THROUGH HEALTHCARE.GOV. The only way to get a tax credit to lower your costs is to buy your insurance through healthcare.gov. Your tax credit will come from the federal tax agency and will be based on your income and family size. Only healthcare.gov can connect with the IRS. We know from statistics gathered in 2018 that approximately 85 percent of Montanans who bought their own health insurance last year qualified for and received a tax credit to lower their monthly bill.
• WITH A TRAINED EXPERT. Hundreds of trained Montanans — including insurance agents, hospital and clinic workers, and others, are certified to help Montanans enroll in a health insurance plan. This assistance is free and you can still qualify for and receive a tax credit if you buy your insurance this way. We keep a list of all the people who can help you under Talk to a Human.
• THROUGH AN INSURANCE AGENT. Your insurance agent may offer health insurance plans outside of healthcare.gov that do or don’t meet the federal insurance requirement. If you purchase a plan outside of healthcare.gov, you will not be eligible for tax credits or subsidies to offset your cost. A tax penalty may apply until January 2019 if you purchase a plan that does not meet federal insurance requirements. A tax penalty is no longer applicable beginning in January 2019.

No matter where you buy it, all health insurance sold in Montana is private insurance offered by private insurance companies.

Plans sold inside healthcare.gov are offered by Montana’s three largest health insurance companies. Together, they sell more than 99 percent of all the insurance sold in Montana. Plans sold inside healthcare.gov are virtually identical to health insurance plans sold outside the site, with some exceptions if the plan is sold only outside the site.

The Montana Health and Economic Livelihood Partnership (HELP) Plan expands health coverage in Montana to adults with incomes up to 138 percent of the Federal Poverty Level (FPL). Coverage began January 1, 2016. The HELP Plan offers medical, behavioral health, dental, vision, prescription drug benefits, and much more. The HELP Plan works to keep you healthy, not just treat you when you are sick.

Three ways to apply:

• Online at healthcare.gov
• Call 1-800-318-2596
• Find in-person help by visiting covermt.org/find-local-help/ or dphhs.mt.gov/hcsd/OfficeofPublicAssistance

What is covered? All the essentials are covered, including:

• Doctor, hospital, and emergency services
• Prescription drugs
• Dental care
• Vision care
• Laboratory and x-ray services
• Maternity and newborn care
• Mental health and substance abuse treatment
• Rehabilitative services and supplies
• Transportation to appointments

Who is eligible? People earning below $17,609 a year, or $36,156 for a family of four who are:

• Montana residents
• Ages 19-64
• Not already in or able to get Medicare

The Affordable Plan for Healthcare:

• No or low monthly premiums depending on your income.
• Small co-pays for doctor visits, with no co-pays for preventive services such as health screenings, help to quit smoking, or flu shots.
• No out-of-pocket above 5% of your total income.

No. Open enrollment for 2021 coverage runs from November 1, 2020 through December 15, 2020. If you haven’t bought insurance during that time, you generally won’t be able to buy during the year.

If you bought insurance last year, that plan will be automatically renewed for 2021 — even if you do nothing. If you haven’t already received it, you should be getting a letter in the mail from your insurance company alerting you to the automatic renewal. However, the only way you can ensure you are getting the full tax credit for which you are eligible is to go back into healthcare.gov and update your information. Even if your income has not changed, we encourage Montanans to re-enter their information. Since you have already created your account at healthcare.gov, it will take you less time to update that information for 2021.

If you do not update your financial information, you may receive a tax credit that is too low — or too high. If you receive a tax credit that is too high, you could be asked to pay money back to the IRS next spring, or the IRS will take the difference from your tax refund.

Insurance plans for 2021 are not the same as last year. You may find a new plan that better meets your needs. We encourage Montanans to shop around here — or elsewhere — to ensure the plan they buy for 2021 is the best one for them.

If you don’t buy insurance during open enrollment, there are a few major changes in your life that can trigger a special enrollment period for you. Major changes include, but are not limited to:

• Losing job-based insurance coverage;
• Marriage or divorce;
• Birth or adoption; and
• Death of a spouse

Deductible is the dollar amount you must pay for medical costs each year before the insurance company begins paying certain claims. Some health plans for sale in Montana do not apply the deductible to certain kinds of services, such as office visits or counseling sessions. Certain care, like immunizations and physicals, are covered even before you pay your deductible.

Federal law caps the amount of money any person or family must pay in a single year on medical costs. This is called your “out-of-pocket maximum.” You might see it written as “MAX OOP” in some insurance documents. If you have insurance just for yourself, your out-of-pocket maximum cannot be more than $8,550 in 2021. If your insurance is for yourself and your family, your out-of-pocket cannot be more than $17,100 in 2021.

A co-pay is a set amount of money you pay every time you receive certain medical care. Not every plan in Montana has co-pays. Co-pays are usually charged instead of a deductible, but plans differ. We recommend researching plans side-by-side below. Some may have a combination of co-pays, deductibles and coinsurance.

Coinsurance is the percentage of your medical bill that you must pay. You usually pay coinsurance after you have met your deductible. For example, if your plan has 20 percent coinsurance for MRIs, you will pay 20 percent of the MRI after you have paid your deductible.

An insurance provider network is the list of all the doctors, nurse practitioners, hospitals, clinics and other health care providers who have signed special contracts with your insurance company. Every company has a network and practitioners can belong to more than one. When a practitioner signs a network contract with an insurance company, they agree to charge certain prices for certain services. In exchange, the insurance company promises to pay for those services. You will want to be sure your doctors are in your company’s network. If they aren’t, the insurance company will make you pay a greater portion of the medical bill. It could cost you up to four times as much to seek care out of your company’s network.