How to Buy Marketplace Insurance

Dec. 17, 2014

Knowing what’s important when choosing a health plan, how to use benefits, and where to turn for help can be challenging for most of us when purchasing health coverage. That’s why the Texas Medical Association started the “Hey, Doc” educational campaign in 2013. We want to help Texas’ patients make the best choice possible when purchasing their health insurance through the new health insurance marketplace. This week we’re discussing the different kinds of health insurance plans available and costs.

What will it cost me to buy this insurance?

Your insurance costs depend on a lot of things like where you live, your age, how many people are in your family, the services you need, and whether you smoke. And your income determines whether the federal government will help you pay for your insurance.

What you pay also depends on which category of insurance you choose in the marketplace: bronze, silver, gold, or platinum. In bronze and silver plans, you might pay a lower monthly charge, called a “premium,” but you might have to pay a higher cost later when you use the insurance. The opposite happens when you buy gold and platinum plans; they tend to have higher premiums and lower out-of-pocket costs.

Here’s an idea of what those costs might look like, on average:

  • In a bronze plan, insurers pay for 60 percent of the charge for medical services; patients, 40 percent.
  • In a silver plan, insurers pay for 70 percent; patients, 30 percent.
  • In a gold plan, insurers pay for 80 percent; patients, 20 percent.
  • In a platinum plan, insurers pay for 90 percent; patients, 10 percent.

You won’t know your costs for sure until you fill out a marketplace application. But until then, you can get a rough idea using this calculator tool created by the Kaiser Family Foundation.

And remember, regardless of whether a plan is bronze, silver, gold, or platinum, don’t forget to check out the other details besides costs, like the kind of insurance and the doctor and hospital networks. Those things are important to keep in mind when comparing your options and choosing a plan that works for you and your family.

What different kinds of insurance can I buy?

There are different kinds of insurance plans you can buy depending on how much you want to spend, the medical services you need for you and your family, and how many doctors and hospitals you want to choose from. Some plans, for example, only let you use the doctors that are in their networks; otherwise, you pay more.

Others might require you to get a referral from your regular doctor before you get other specialized treatments. You can read up on Healthcare.gov and BeCoveredTexas.org about the different kinds of insurance plans out there.

The marketplace also puts these different kinds of insurance plans into four categories: bronze, silver, gold, and platinum. The categories are based on the amount of coverage the insurance company provides for your health care, and your portion of the costs. But again, any plan in any of those categories still has to offer essential benefits. The difference is how you and your insurance company share the costs of that care.

There is a fifth option, too, called “catastrophic insurance.” But it’s only for certain people, and it doesn’t cover everything.

When does my coverage start?

During open enrollment for 2015, if you enroll:

  • Between the first and 15th day of the month, your coverage starts the first day of the next month. So if you enroll on Jan. 5, 2015, your coverage starts on Feb. 1, 2015. And remember Dec. 15, 2014, is the last day to sign up for your coverage to take effect on Jan. 1, 2015.
  • Between the 16th and the last day of the month, your coverage starts the first day of the second following month. So if you enroll between now and Dec. 31, you coverage will start Feb. 1.
  • Between Feb. 1, 2015, and the deadline of Feb. 15, 2015, your 2015 coverage begins March 1, 2015.

You can find each week’s “Hey, Doc” Q&A and a lot more at texmed.org/Heydoc as well as in TMA’s patient blog at MeAndMyDoctor.com. And TMA produced “Hey, Doc” videos to help people understand how to navigate the marketplace. 

Below is TMA’s “Hey, Doc” content schedule through January 2015.

Dec. 30: What is catastrophic insurance? What is covered by this insurance? 

Jan. 7: How Do I Pick a Plan? How Many Plans Can I Pick? Can I Keep the Plan I Have Now?

Jan. 14: Who will take care of me? What are the networks? How do I pick a doctor? Where can I find this information?

Jan. 21: Can I keep my doctor or hospital when I sign up? How do I find out if my doctor is on my insurance plan’s list? What should I do if I thought my doctor was included but really isn’t?

Jan. 28: Why is it important that I pay my insurance premium on time? How do I know what kind of coverage I have and if I can use my insurance?


TMA is the largest state medical society in the nation, representing more than 48,000 physician and medical student members. It is located in Austin and has 110 component county medical societies around the state. TMA’s key objective since 1853 is to improve the health of all Texans.

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Contacts: 

Brent Annear
phone: (512) 370-1381
cell: (512) 656-7320
 
Brent Annear 

Marcus Cooper
phone: (512) 370-1382
cell: (512) 650-5336
Marcus Cooper  

Click here to follow TMA on Twitter. Or visit TMA on Facebook. 

Check out  MeAndMyDoctor.com for interesting and timely news on health care issues and policy. 

Last Updated On

March 14, 2018