Is Obama Care Right for You? 5 Things You Need to Know About Open Enrollment Season

Khang T. Vuong, MHA
Khang T. Vuong, MHA13 Jul 2021

Every year since 2013, millions of Americans are signing up for affordable health insurance via the Affordable Care Act Exchange (aka Obama Care) beginning the first day of November. While it is less likely a joy for some, it is an important annual event that can impact your healthcare for the next year to come.

What‚s different this year? Because the tax penalty (aka the individual mandate) was effectively repealed in late 2017, there will be no penalty for not having insurance. Except for CA, DC, MA, RI, and VE.

Getting healthcare benefits can very confusing, especially when money is tight, and there seem to be more and more options as the years go by. But with years of experience working in healthcare, here are the five things suggest you should know:

1. Enrollment deadline is December 15, 2019

To receive benefit starting January 1, 2020, you must sign up before the Open Enrollment period is over. You have 45 days from November 1 to December 15 to decide which plan is right for you.

There are exceptions in some states, however:

  • California ‚Äì Oct. 15, 2019-Jan. 15, 2020
  • Colorado ‚Äì Nov. 1, 2019-Jan. 15, 2020
  • D.C. ‚Äì Nov. 1, 2019-Jan. 31, 2020
  • Massachusetts ‚Äì Nov. 1, 2019-Jan. 23, 2020
  • Minnesota ‚Äì Nov. 1, 2019-Dec. 23, 2019
  • New York ‚Äì Nov. 1, 2019-Jan. 31, 2020
  • Rhode Island ‚Äì Nov. 1-Dec. 23, 2019
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2. There are four tiers of insurance you can get, starting at $440 monthly

According to eHealth, premiums for individual coverage for a single person increased by 2% to $448 in 2019. If you make less than $49,000 on an individual basis, you may qualify for a tax subsidy that helps lower payment. The amount, however, is unclear.

eHealth said the average premiums for individual coverage were:

  • Bronze -- $440
  • Silver -- $481
  • Gold -- $596
  • Platinum -- $706

For family coverage, the average premiums were:

  • Bronze -- $1,080
  • Silver -- $1,179
  • Gold -- $1.426
  • Platinum -- $1,460

Deductible (the amount you have to pay out-of-pocket before health your insurance starts paying): 

According to the same survey, the average deductible is $4,300 for an individual and $8,300 for a family, likely higher for the 2020 enrollment year.

The most popular plan in the individual market is Bronze. Forty-one percent have a Bronze plan. Silver came in second with 35%. Thirteen percent have Gold plans and only 2% chose a Premium plan.

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3. Be wary of the details: copay, deductible, narrow network.

The ability to afford insurance is very important, especially when you have to take care of healthcare benefits on your own - self-employed, independent contractors, small businesses.

While many will likely go for the lowest-cost plans, it is important to know the details. Here are a few things you must know:

  • Deductible: the hallmark of modern health plans, it is the amount you must pay 100% out-of-pocket before your policy starts paying.
  • Copay: you share a small portion of the cost, BUT ONLY if you have met your deductibles.
  • Free preventative visits: you get up to 2-3 free visits, but only for vaccination, physical exam, wellness visit, and for screening like colonoscopy and mammography. Having the flu, sports injuries, or getting an X-ray is counted as a sick visit you have to pay on your own.
  • Narrow network: new health plans are designed with a narrow network of doctors you can go to. Accidentally going outside of the network means not only you have to pay out-of-pocket, but also 2-3 times higher than the negotiated price.

4. There are ways to reduce out-of-pocket costs

Because you have to pay 100% out-of-pockets for most common healthcare needs like sick visits, X-Ray, prescription refill and so on. And, sometimes, paying cash can save you more than you think. It is smart to find new ways to save on healthcare costs.

For example, an urgent care visit typically has a $100 copay. However, because you haven't met your deductible, and healthcare pricing can often be obsured, you end up having to pay $300 out-of-pocket. Because of this, many people are opting out of insurance benefits for cash discounts when it comes to day-to-day medical services like urgent care and primary care. 

GoodRX helps you find coupons for prescriptions. And, sometimes paying cash with a coupon for drugs can save you 80-90% compared to paying via insurance.

Mira helps you get fixed price urgent and primary carecare appointments for common health needs at a 50-60% cheaper compared to going with insurance rates. For only $25 a month, Mira covers 22 most common conditions at a $99 fixed copay, regardless of your health plan.

Mira can also be used without an insurance as a stand-alone benefit. Adding Mira on top of a high deductible health plan makes perfect sense for those who are looking to minimize monthly premium cost while still getting the predictability and reliability of accessing healthcare.

For example, having common flu can cost you $250 at urgent care centers with a $150 prescription for TamilFlu, a total of $400. The same appointment would cost $99 with Mira and $34 for the prescription with GoodRx, a total of $133 or a 300% savings.

Khang T. Vuong, MHA

Khang T. Vuong received his Master of Healthcare Administration from the Milken Institute School of Public Health at the George Washington University. He was named Forbes Healthcare 2021 30 under 30. Vuong spoke at Stanford Medicine X, HIMSS conference, and served as a Fellow at the Bon Secours Health System.