So how’s your “open enrollment” going for your individual health insurance plan? Do you know what you need to do by Jan. 31, 2017? I hear ya! As an independent, licensed insurance agent who specializes in health insurance and group benefits, there are things about the health insurance system that confuse the dickens out of me, too! In my role, a lot of time is spent helping people navigate various health insurance options. If you have a health insurance policy through an employer, chances are they do most of the decision-making. Some employers might even give you a limited set of choices to help find the best policy for your health care needs.

However, if you are purchasing insurance through the individual market, determining the right policy now becomes your job. Many folks will try to figure out their choices on their own. Before the Affordable Care Act took precedence in 2014, I spent time helping families figure out what deductible, co-insurance and/or co-pays worked best for them. Today, there are several other components to consider that will definitely affect how well a chosen insurance policy works for each individual’s needs.

The most common questions concerning individual insurance plans are: Do I qualify for a subsidy? And if so, how much? This is a huge part now in making health insurance affordable. Right now if your income is between 101 and 400 percent of the federal poverty level in Wisconsin, you qualify to receive help on paying your qualified health insurance premiums. If it’s between 101-250 percent, you may even qualify for help with your deductible, co-insurance, and copays. A great resource to use to see where you are in the federal poverty level is KFF.org.

Another common question is: What happens if I’m wrong when I guess what my household income will be for 2017? It’s important to keep track of your income reality (versus your estimate) during the course of the year estimated. If you underestimate your income, you will be paying the amount that you don’t qualify for back when your tax bill is due. If you overestimate, the converse is also true. You can also contact the Marketplace during the year to adjust the subsidy amount. Remember if you want to receive a subsidy, coverage must be purchased through the Marketplace. If you don’t qualify, you can go directly to the insurance company.

To put this into personal terms, here are two different sets of circumstances surrounding two clients in need of a health insurance policy: Client A and Client B.

Client A is a single female in her late twenties who makes about $17,000 a year. She is self-employed with some health concerns. Last year, she told me that she didn’t want to look at subsidies, so I’m guessing that that decision cost her a couple thousand dollars over the course of the year. This year, I strongly suggested she consider the financial help she would receive when purchasing a “silver” plan through the Marketplace. The renewal cost in 2017 pushed her monthly premium to more than $500 a month. But because she qualified for a subsidy of over $400 per month, her monthly health insurance cost after a subsidy will now cost her less than $100 per month. Because of her income level and the plan she is choosing, she will also receive help with her total out-of-pocket amounts as well. However in order to qualify for this price, she has to go through the Marketplace. 

Client B is a small business owner with a large family. Because of the size of the family, they qualified for a subsidy of $1,200 a month in 2016. However they feel very adamant about staying out of the Marketplace, which means they will not qualify or receive any subsidies to help offset insurance costs which run about $1,500 month. Although I respect their decision, it is a huge cost commitment on behalf of the family. We’ll see if that is what they do for 2017.

Another large consideration now is making sure that your providers (specific doctors, choice clinic or hospital, pharmacy, etc.) are covered by the health insurance plan. This has always been part of the insurance conversation. One response to the ACA has been to utilize very narrow networks as a way to contain costs. Nonetheless, this decision has caused a ton of concern. People who are healthy will consider changing their doctor if the cost is worth it, but folks who have significant health issues are typically very reluctant to change, or they can’t due to treatment plans.

So, are these decisions simple or what? It is important to remember that in the event an individual insurance policy is needed the open enrollment period is from Nov. 1 through Jan. 31. There are certain exceptions such as losing your qualified plan during the “middle” of the plan year, moving out of the area your plan covers, births, deaths, divorce –  all of which cause you to lose your coverage. Not paying your premium though, doesn’t constitute a special enrollment period, so be careful! To help you get it right, I strongly suggest the help of a certified health agent.