Health Insurance 101: How to Navigate the Marketplace

September 16, 2020 / By Molina Healthcare

Health Insurance 101: How to Navigate the Marketplace

What’s your best option for health coverage?


A lot of people aren’t sure, especially because the past few years have brought multiple changes. If you’d like some clarity to help you navigate what’s out there, read on for explanations of different types of plans and common health care terms.


What’s the difference between Medicaid, Medicare and the Health Insurance Marketplace?

All three of these plans are funded by the government to help people get medical care. Traditionally, Medicaid is for those with a low income. But because of the impact of COVID-19 on income and wages, you may qualify for Medicaid now even if you never did before.


Medicare plans are for senior citizens and people with disabilities. Some folks qualify for Medicare and Medicaid. Both programs were designed to pay all a member’s medical expenses.


What is a Marketplace plan?

When people talk about Obamacare, this is what they’re referencing. Created during Barrack Obama’s presidency when the Affordable Care Act (ACA) was enacted by congress, Marketplace plans share the cost of care with members. This happens in a number of ways. To compare plans, it’s important to understand them.


Premiums, deductibles, co-payments, out-of-pocket costs and coinsurance, explained

Premium = a payment you make each month in order to keep your coverage, like with car insurance. If your employer provides insurance, they likely pay part of your premium.


Co-payment or co-pay = a specific fee you owe your provider when you get care. For instance, your plan might call for a $25 co-payment when you see your primary care physician and a $200 co-pay if you go to the emergency room.


Deductible = the amount you must pay before your insurer starts covering a larger percentage of your bills. If your plan has a $500 deductible, for example, and you incur a big hospital charge, you must pay $500 before your insurance company starts covering a higher portion of costs. Every year, the deductible resets.


Coinsurance = the part of a medical expense you pay, while your health plan handles the rest—usually after you’ve met the deductible. You might have a 10% coinsurance, for instance. That means you cover 10% of every bill and your health plan pays 90%.


Out-of-pocket maximum = the most you have to pay in one year for your health care out of your own pocket before your insurance covers 100% of the bill.


But how to choose?

Generally speaking, people who expect to get a lot of care go with a plan that has a higher premium and lower deductible. And those who don’t see the doctor often – maybe people who are younger and in basic good health – might choose a low premium and high deductible.


Category: Health Insurance