What's the deal with non-Marketplace health plans?

[disneysteve]

I'm looking at our state (NJ) exchange to sign up for coverage. There are 80 plans to choose from. When I filter out for just Silver, there are 44 but about half of those would cost more than we're paying for COBRA so those are out bringing me down to about 18-20 options. A few of them say they are "not a marketplace plan". What does that mean and what significance does it have? If the terms and costs are comparable, what potential downsides are there to choosing a plan that is not a marketplace plan?

 

[disneysteve]

And just as a more general question, how do you narrow down your choices? Our daughter just picked her 2024 coverage at work today and she had 3 options, not 23. How do you sort through that mess and make a reasonable decision? I already entered a few providers who we'd want to have covered.

 

[MichaelB]

“Not a marketplace plan” but still compliant with ACA means you contract directly with the insurer, they don’t pay marketplace fee, but it’s not eligible for subsidy or premium assistance.

With Florida BCBS they have 3 plans with around 30 or so variations in cost sharing. The coverage in all ACA compliant plans is the same. They really have only 3 plans. What differs between is the size of the provider network. One is an HMO, one is a limited network PPO, and one is a large nationwide provider network.

Each of the 3 has different combinations of premium, deductible, copay and total out of pocket, If you take on more risk, with a higher deductible and total out of pocket, your premium is lower.

 

[Aerides]

And just as a more general question, how do you narrow down your choices? Our daughter just picked her 2024 coverage at work today and she had 3 options, not 23. How do you sort through that mess and make a reasonable decision? I already entered a few providers who we'd want to have covered.

Don't ignore Bronze.

I filter for HSA, and PPO, and then for preferred docs.

 

[gauss]

+1 to either Bronze, (or catastrophic if you can qualify). Note HSA contributions are not permissible with a catastrophic plan.

-gauss

 

[disneysteve]

Don't ignore Bronze.

I filter for HSA, and PPO, and then for preferred docs.

There are no PPO options, just HMO and EPO, unless I'm missing something. no PPOs show up on the state marketplace website.


The Bronze plans look like they have much higher deductibles and office visits cost more (and drugs might also) so I need to figure out if paying thousands more out of pocket will be adequately offset by the lower premiums.

 

[MichaelB]

There are no PPO options, just HMO and EPO, unless I'm missing something. no PPOs show up on the state marketplace website.


The Bronze plans look like they have much higher deductibles and office visits cost more (and drugs might also) so I need to figure out if paying thousands more out of pocket will be adequately offset by the lower premiums.

The EPO plan is probably the same as a PPO. Here’s an excel spreadsheet (here) that lets you enter different premiums, deductibles, copy-pays and even medical expenses to compare the total cost.

 

[SecretlyFI]

For the OP - did you decide on a plan? I am also in NJ and will be choosing soon. I had also noticed no PPO’s. From your research, does it seem that EPO’s are similar enough, as MichaelB indicated?

 

[Scuba]

I can’t speak for New Jersey, but we just did a thorough review of health plans available in FL. There was a “non-ACA compliant” plan a couple of different consultants suggested for me. It had a significantly lower premium than ACA compliant plans, and required medical underwriting to qualify. Since I have no significant pre-existing conditions, the agents felt I would likely qualify. However, after reading online reviews of the coverage denials when large claims occur for people with these types of policies, I decided to go with an ACA plan. We have never had an ACA plan because DH was on a grandfathered plan, but he is going on Medicare soon and we moved from CA to FL so we were forced to change.