Consumer Connection: Shopping for Health Insurance

By Sonya Sellmeyer, Consumer Advocacy Officer for the Iowa Insurance Division

Open enrollment for the Affordable Care Act (ACA) began on Friday, November 1, 2024 and ends on Wednesday, January 15, 2025. During open enrollment you may enroll in a new plan, switch plans if you are currently insured, or make changes to your individual health insurance plan for 2025.

Before shopping for the best health insurance options for you and your family on healthcare.gov it's essential to understand a some basic terms and concepts:

Premiums: This is the amount you pay each month for your insurance coverage. The quoted amounts on healthcare.gov are for individual premiums, not families. You may be eligible for premium tax credits which will lower your premium. The amount of your premium tax credit will depend on your estimated household income that you submit on your application.

Deductibles: This is the amount you must pay out-of-pocket for healthcare services before your insurance starts to pay. Generally, plans with lower monthly premiums have higher deductibles.

Copayments and Coinsurance: Copayments are fixed fees you pay for specific services (like doctor visits), while coinsurance is the percentage of costs you share with your insurer after meeting your deductible.

Network: This refers to the group of doctors, hospitals, and healthcare providers that have agreements with your insurance company to provide services at reduced rates and may be a Health Maintenance Organization (HMO) or Exclusive Provider Organization (EPO). A HMO plan limits coverage to those doctors who contract with the HMO, require you to select a primary care physician, get referrals to see specialists, may require you to live or work in its service area to be eligible for coverage, and may not cover out-of-network providers except in the case of an emergency. An EPO is a managed care plan where services are only covered if you use the network's doctors, specialists, or hospitals, except in an emergency.

Rating Area: The area of multiple county regions that health insurance companies use to set their rates, and thus, different policies are offered in different counties.

Metal Level: Plan choices under the ACA fall into different metal levels based on the portion of health care expenses the plan covers: Bronze Plan 60%, Silver Plan 70%, Gold Plan 80%, and Catastrophic Plan 60% which is generally limited to those under the age of 30.

Not sure which metal level to pick? Think about how much you spend on health care, what the plan covers, enroll in the silver plan if you qualify for extra savings or cost-sharing reductions, consider your premium tax credits which will lower your premium regardless of metal level, and the plan's quality of care rating which is a scale of 1-5.

Outside of the open enrollment period, you can only enroll or make changes if you experience a qualifying life event, such as getting married, having a baby, or losing other health coverage.

Shopping for health insurance is a crucial task that requires careful consideration and planning. If you need help to understand and shop for health insurance, contact a licensed insurance agent or a navigator. The Iowa Insurance Division also has health insurance information on their website at iid.iowa.gov or may be reached at 877-955-1212.

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