When shopping for health insurance, you should consider:
- how much medical care you will need,
- the total health care costs including out-of-pocket costs, and
- if your preferred doctors are included in the plan’s network.
Medical Care Need
To help you find the plan that is right for you, you should think about how much medical care you will need.
Health plans in the Marketplace are in “metal” categories: Bronze, Silver, and Gold. The categories are based on how you and your plan split the costs of your health care. In general:
- Gold plans have higher monthly premiums but pay more of your total cost of health care. You pay less when you need care.
- Silver plans have mid-range premiums and generally lower costs when you need care. Read more about Silver plans and possible extra savings below.
- Bronze plans have lower premiums and pay less of your total cost. You pay more when you get care.
How to decide which health plan level is best for you
Only you can make the best decision on which health plan level best fits your medical, financial, and personal needs.
If you don’t expect to use medical services often and don’t take prescriptions regularly, you may want a plan with lower monthly premiums. These plans often have higher costs when you need care.
If you qualify for "cost-sharing reductions (CSRs)," you will need to choose a Silver plan to get extra savings. If you qualify, your deductible will be lower. You will pay less each time you get care. If you don’t qualify for CSRs, a Silver plan may still meet your needs.
If you expect a lot of doctor visits or need to take prescriptions regularly, you may want a plan that covers more of your out-of-pocket costs when you receive care. These plans generally have higher monthly premiums.
Compare premiums and out-of-pocket costs. Choose the one that fits your budget.
Total Health Care Costs
When you compare costs, consider your total health care costs and not just the monthly premium. Other out-of-pocket costs have a big impact on your total health care spending:
Deductible: How much you have to spend for covered health services, except free preventive services, before your insurance company pays anything
Co-pays and co-insurance: What you pay each time you get a medical service after you reach your deductible
Out-of-pocket maximum: The most you have to spend for covered services in a year. After you reach this amount, the insurance company pays 100% for covered services.
You can use the GetCoveredNJ shop and compare tool to get an estimate of your total health plan costs, including monthly premiums and all out-of-pocket costs. The estimate is based on your household’s expected use of care. Your actual expenses will be different. But the estimate will help you understand how each plan will affect your household budget.
You should also look at what the plan covers. All plans must cover basic medical services – called “essential health benefits” – but there are some kinds of medical care that will not be covered and you will pay more for them.
Costs also be higher or lower if you get your care from certain doctors, hospitals or other providers.
Check your health plan’s Summary of Benefits and Coverage for more detailed information.
Plan and Network Types
Health plans are designed to meet different needs. Each plan has a “network” of doctors, hospitals, and other providers that offer covered care. Some health plans require you to choose a primary care physician (PCP) to coordinate your care. The health plans may also require referrals when you see specialists. Other plans may not require a PCP or referrals.
If you have a doctor you want, find out if they are in the plan’s network. You can check if your doctor is in a plan network when you compare plans and cost using our shop and compare tool.
Some plans have provider levels in their network. The providers are all in the plan network. But you may pay more to see some providers. Most plans do not cover services provided by doctors or other providers outside of the plan network, except in the case of an emergency.
Your premium can be lower, based on your income
No matter which level you choose, Gold, Silver or Bronze, you can save money on your monthly premium based on your income.
You can find out if you qualify for financial help on your monthly bill. To do a quick check now, use our shop and compare tool.