So no one told you health insurance would be this way…

Health insurance is complicated and no one teaches you how it works, so OSPIRG intern Ashley Hilfer breaks down the basics.

Health care

Explainer

March 29, 2021

Maribeth Guarino

High Value Health Care Advocate, OSPIRG

Ashley Hilfer is a junior at Portland State University, majoring in Nonfiction Creative Writing and minoring in Political Science. She’s currently interning with OSPIRG on campaigns for high value health care. When she’s not working or writing, she loves to hike, read, perfect her baking skills, or work through her Netflix catalogue.

Let’s get straight to the point: the American health care system is not easy to navigate.

It wasn’t something I even thought about until high school, but it was when I started college and got a job that employed me just under full-time that I realized health care, specifically health insurance, was something I needed to worry about. More often than not, getting automated emails and pamphlets from my employer about health insurance only added to my confusion rather than clarifying anything. I didn’t know what “good” coverage was or if the price of a certain plan was reasonable; I had no idea what options there were for me, so I didn’t look beyond what was given to me by my employer, and even that information was something I just barely had a grasp on.

Now, three and a half years later, my growing interest in politics has led me to interning with OSPIRG on their health care campaign. While I’m nowhere near an expert, I’m constantly learning more about how the health care system works. With the knowledge I’ve gained so far, I want to break down the basic building blocks of health insurance and give you a new sense of confidence when navigating the system. So, let’s get started!

Firstly, I want to clarify some key terms that stumped me when I was first learning about health insurance:

Premium: The monthly payment for a plan, which can be on a wide spectrum.
Deductible: The yearly amount you pay for a covered service/medication before your insurance starts to pay.
Coinsurance: The percentage of costs for a covered service/medication after you’ve met your yearly deductible.
Co-Pay: The set amount that you pay each time you go to the doctor or get a prescription.
Out-of-Pocket Maximum: This is a yearly cap for the amount you pay for covered services/medications. Your copay, coinsurance, and deductible payments all count toward this maximum, and once it’s reached your insurer will cover all your medical expenses until your spending resets at the start of the following year.
Subsidies: Tax credits that, if you qualify for, can be applied to lower monthly premium costs when shopping for a private health insurance plan.

Now with these terms defined, let’s tackle the million-dollar-question:

“How do I get insurance?”

In the United States, there are 3 main ways to get health insurance:

Government Programs

Medicare: A federally-funded program for retired, 65+ seniors.

Medicaid: A joint state and federally-funded program for those who are low-income and in need. There are certain requirements in order to be eligible, but you can enroll any time. In Oregon, this is done through the Oregon Health Plan. You can see if you’re eligible for this program here.

Employment-Based

This is how many working Americans get their insurance coverage. Through this option, your access to healthcare is tied to your employment status. Employers may also have additional requirements in order to be enrolled in a plan through them, such as being a full-time employee.

In certain situations, you can also get health insurance through a family member’s employer. It’s important to note that under the Affordable Care Act, if an employer offers health insurance to an employee’s family members, those family members are not eligible for subsidies if on the Marketplace, what’s referred to as the ‘family glitch” population. In addition, employers often contribute less to family coverage than to their employee’s plan. For many families, this can often lead to both options being unaffordable.

The Healthcare Marketplace

Consumers also have the ability to purchase a plan on the federal HealthCare.gov website. Subsidies to help pay premiums are also available for those meeting certain income requirements, and the federal website provides a tool to check if you’re eligible for any of these savings.

“When can I buy a plan on the Marketplace?”

Now that we’ve gone over the options to get health insurance, there’s one more key piece of information if you’re shopping for a plan on the Marketplace: the WHEN. If you’re the type of person that needs to keep tightly organized, like I am, and are planning to shop for a plan on the Marketplace, that’s a critical question.

Stock photo courtesy of Waldemer Brandt (Unsplash)

The period when you can buy a health insurance plan on the Marketplace is called open enrollment, and it happens from November 1st through December 15th every year, with your coverage starting on January 1st of the new year.

There’s also a special enrollment period if you have a Qualifying Life Event (QLE). This includes getting married, having a child, or if you lose your coverage outside of the open enrollment period. If you meet the qualifications for a QLE, then you have 60 days from that event to enroll in a plan through the federal website.

The federal government has also opened a special enrollment period due to the pandemic, running now through May 15th. If you haven’t already signed up for health insurance, check out the Marketplace to see your options.

And with that, you have a basic understanding of health insurance and how to get coverage. I hope this information gives you more confidence in navigating the system, as it did for me. If you have more questions, you can look at the marketplace’s FAQ, check out OSPIRG’s Facebook page to view our open enrollment webinar from March 10th, or comment below!

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Authors

Maribeth Guarino

High Value Health Care Advocate, OSPIRG

Maribeth stands up for the public interest in Oregon, working to advance the High Value Health Care campaign. A recent transplant, Maribeth is delighting in all the new hiking trails she gets to explore and photograph.