Questions To Consider When Purchasing Health Insurance


The importance of having health insurance can be as simple as lowering routine medical costs or as vital as it being the main protection against financial ruin due to a personal health crisis. Whether choosing a policy offered through an employer or on the individual market, here are a few questions to consider before deciding on the most suitable plan option.

What type of plan?

The Patient Protection and Affordable Care Act (ACA), passed in March of 2010 under the Obama Administration and coined “Obamacare,” is not an insurance plan but a series of provisions required to be covered in a Qualified Health Plan (QHP) also known as an ACA plan. Taking effect in 2014, plans designed under this law are required to cover 10 essential health benefits to be considered a QHP. Defined by the National Academy of Medicine those benefits include, ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral treatment; prescription drugs; rehabilitative and habilitative services and devices; lab services; preventative and wellness services and chronic disease management; and pediatric services, including oral and vision care.

A significant benefit to highlight, which can truly be a game changer in lowering the overall cost of care per person is access to FREE preventative healthcare. Screenings like colonoscopies, immunizations, lab work and blood testing, are just a few of the many $0 preventative services that can not only give an insured the “peace of mind” with knowing the status of their overall health but more importantly be the reason for early detection and treatment of a potentially devastating illness.

The cost of ACA plans purchased through the Health Insurance Marketplace depends on household income and size. For example, a married couple, both age 55, with the median annual income for a household of 2 in Orange County, Florida of $77,250 (according to the Orange County Housing and Community Development Division as of April 2024), can expect to pay less than $200 for the lowest costing ACA plan available in Orange County, Florida. Another couple the same age, residing in the same county, with a household income of $39,440 could find a plan for $0 per month or a plan less than $100 per month with significantly lower copays for covered services.

Continuing with the scenario of a 55-year-old pair, in this case with an income over $250k, would be over the limit to receive a credit to lower their monthly cost for an ACA plan and would have to pay about $1,400 per month for the lowest costing plan options that still do cover free preventative care. In case this couple feels “priced out” of an ACA option due to a higher income, are in good health, and are primarily concerned with having protection against a potential financial ruin due to a health emergency or crisis, a Non-ACA or Short-Term Medical plan can be an alternative. The couple can expect to pay less than half the lowest ACA option, at around $650 per month. This is a type of plan that neither covers pre-existing conditions nor free preventative care but will cover them for any health emergencies over $5k. These plans typically have maximum dollar amounts that the insurance carrier will cover for the duration of the term. Also, a carrier can choose to accept or deny an applicant as the plans have underwriting questions while ACA plans do not.

What type of network?

Familiar acronyms such as HMO, PPO, POS, and in recent times the more prevalent EPO, are the primary networks that allow an insured access to select providers and facilities, and additionally the range in which they can utilize them.

As far as cost is concerned, a health maintenance organization (HMO), is usually the lower of the bunch. It requires a primary care physician (PCP) to serve as the conductor of an insured’s health care. In order to see a specialist doctor, you must receive a referral from your primary care physician. HMO’s usually have a smaller managed network of doctors and facilities than the others but not always. If a provider is not in the HMO’s network, the insured cannot expect services to be covered unless it is deemed a “true emergency.” Those are a few ways that insurance companies can justify the lower monthly cost of these plans. As long as the providers an insured needs to see are in-network, this is a very cost-effective option for one to consider.

Preferred Provider Organizations (PPO) offer the flexibility of seeing a doctor out of the plans network, usually for a higher cost. Neither a PCP nor a referral is required. PPOs tend to be the largest of all networks and the highest costing option. This would be recommended to someone who needs access to specific providers or may need services out of the state.

Exclusive Provider Organization’s (EPO) have qualities of both HMO’s and PPO’s. Like PPO’s, no referral is required to see a specialist and like HMO’s, no services are covered out of network. This is ideal for someone that likes access to a specialist without needing a referral and does not want to pay the cost of a PPO. Another hybrid to consider at lower cost than a PPO is a Point of Service (POS) plan. Like HMO’s, they have a smaller managed network of providers however, like a PPO, an insured can choose to see an out of network provider at a higher cost.

How and where to purchase a plan?

As of 2024, if an employer offers ACA plans through group insurance at a monthly rate less than 8.39% of an employee’s household income, it is considered “affordable care” and is more than likely the most suitable option in this case. As employers are not required to contribute towards the cost of health insurance for dependents of an employee, adding them can be costly and it may be best to consider coverage for them through the Health Insurance Marketplace.

The Marketplace offers coverage for individuals and families who do not qualify for full Medicaid, Medicare, or employer group health coverage. Based on household income, household size, residing county, a shopper can receive an advanced premium tax credit that goes towards paying the monthly cost for having a health plan. Access to health insurance tax credits are available to non-citizens as well as long as they have eligible immigration status. For most in Central Florida, dozens of plan options are available from various insurance carriers.

With so many options, shopping for the right plan can be a daunting task to check off a to do list. As a licensed health insurance agent, active since the start of the Affordable Care Act, I have had the opportunity to serve many everyday Floridians choose the right health plan. As myself and other seasoned agents have seen many different scenarios of cases from our community, I highly recommend using an agent when purchasing a health plan as we can address any questions or concerns and can smoothly navigate a prospective buyer into the best suitable plan to meet their needs. Furthermore, an agent can assist throughout the year with plan servicing or issues and act as an extension of the insurance company they represent. Lastly, agents are compensated by the insurance company as well so there is no cost for the buyer to utilize their expertise when purchasing health insurance. To learn more call Marlon Miller with Orca Insurance Group at 407-604-2484.