Out-of-Pocket Costs
When choosing a health plan, it's wise to consider all health care costs involved, not just the plan's monthly premium.
These other health care expenses are known as out-of-pocket costs and typically have a big impact on your total health care expenses. At times these expenses are more than your monthly premium.
Deductible and Out-of-Pocket Costs
Deductible - The amount you must spend for covered health services before your insurance carrier pays anything (except for preventive services)
Copayments - A set amount you pay for prescriptions, doctor visits, and other types of care once you've reached your plan's deductible
Coinsurance - A percentage of costs you pay for prescriptions, doctor visits, and other types of care once you've reached your plan's deductible
Maximum out-of-pocket - The maximum amount you have to spend for covered services in a calendar year. After reaching this amount, the insurance carrier pays 100% of all of your covered services
Estimating Your Total Yearly Care Costs
When estimating your total yearly costs for health care services, think about how much care you use or are likely to use based on previous years' usage. Although it's impossible to predict the exact amount of your costs, you can at least have a good idea of what to expect for the upcoming year. Our licensed benefit advisors* can help you choose a plan that meets your needs, based on your and your family's expected health care usage and budget.
Total Costs and Metal Categories
When comparing plans in the health insurance marketplace, note that the plans appear in four “metal” categories (Bronze, Silver, Gold, and Platinum). Each category is based on how you and the health plan share your total cost of care.
In general, Gold and Platinum plans have higher premiums, which may result in lower out-of-pocket costs when using medical services. In contrast, Bronze and Silver plans have lower premiums, which may result in higher out-of-pocket costs when using medical services.
Consider the following when determining the category that works for you:
If you don't expect to use health care services regularly and don't take prescription drugs, you may want a Bronze plan. These plans often have low monthly premiums. However, you may pay more towards your medical costs, such as higher deductibles or higher maximum out-of-pocket costs, than you would with other metal tier categories that often have higher premiums.
You may be eligible for cost-sharing deductions by enrolling in a Silver plan and meeting income requirements. If you qualify, your deductible is lower and you pay less each time you get care.
If you expect several doctor visits or need prescription drugs on a regular basis, you may want a Gold plan or Platinum plan. These plans generally pay more of your costs when you need care. However, they have higher monthly premiums.
Finding Costs for Health Care Services
You can find costs for health care services by viewing an insurance carrier's Summary of Benefits and Coverage (SBC). Every plan an insurance carrier offers must provide you with access to this document. The SBC for a plan outlines what services are covered (and not covered), along with their associated costs. The SBC is a useful tool in helping you compare costs and in understanding your coverage options. Our benefit advisors are familiar with the SBCs and can help determine which plan fits your specific health care needs and budget.
For your convenience, a link to a plan's SBC is available each time you preview the plan, whether it's on marketplace.viabenefits.com, healthcare.gov, or the insurance carrier's website. Once you have enrolled in a plan, you may ask for a copy of the SBC from your insurance carrier at any time.
*Our licensed benefit advisors specialize in health insurance for retirees. They go through annual training and certification to ensure they can help you make an informed and confident decision.
