Tips for Families Considering Private Coverage Through the Marketplaces

Millions of Americans have enrolled in private coverage through the health insurance Marketplace over the last two years. We’re nearing the mid-point of the third open enrollment period, when even more are expected to enroll. Most of these enrollees are adults, since children often qualify for coverage through Medicaid or the Children’s Health Insurance Program (CHIP). But the Marketplace is still an important source of health coverage information and a door to enrollment for families with children.

PEscreenshot.JPGThe process of comparing and choosing a private insurance plan through the Marketplace is quite different from health insurance enrollment experiences families may have had in the past. One significant challenge is ensuring the plan covers all of the services and providers necessary to meet your children’s needs. Here are tips to help with the process and ensure families find a plan that meets their children’s health care needs and fits within their budget.

1. Make a list of health care providers you and your children currently see. Include hospitals, doctors, therapists and other community providers. Provider networks vary widely from one plan to the next, so before you start your search, have your list of needed providers ready. REMEMBER: If you have children, you should check to ensure there is a children’s hospital in the plan network in case your child ever needs specialized care. You may need to pay more out of your own pocket if your provider, including a hospital, is not in the provider network.

2. Estimate how much health care you and your family will need. Make a list of the kinds of services you and your family receive in a typical year. Does anyone have disabilities, chronic or complex conditions or regularly see specialists? Is anyone in the household expecting to become pregnant in the year ahead? Keep these needs in mind as you compare plans and remember that some people in your family may be eligible for Medicaid as well if they have a disability. The Marketplace can help you determine that eligibility.

3. Get an estimate of how much premiums might cost. Last year, four out of five Marketplace enrollees qualified for financial help. Get Covered America offers a simple calculator to help families estimate premium costs based on household size, ZIP code, and income. The calculator results will also tell you if you or your children might qualify for Medicaid or CHIP instead based on your income.

4. There’s more to health care costs than premiums. Preventive care services (like vaccines and hearing and vision screenings for kids) are free when received by in-network providers. But, most other health services require a copay or coinsurance, and many plans require enrollees to meet a deductible before their coverage “kicks in.” The out-of-pocket costs are higher when the provider you see is not in the plan’s network.

  • Plans with lower premiums (like catastrophic and Bronze plans) typically have higher deductibles and other costs that you will have to pay (“out-of-pocket” costs). These plans may be best if you and your family are relatively healthy, prefer a lower premium and can afford to pay a lot out-of-pocket if you or a family member needs care.
  • Plans with higher premiums (like Silver, Gold or Platinum plans) typically have lower deductibles and out-of-pocket costs. These kinds of plans may be best if you know you will have regular health care needs, can afford a somewhat higher premium and want the peace of mind of lower costs when you get care.

 REMEMBER: If your family income is below a certain level and you choose a Silver level plan, you will qualify for a cost sharing reduction that will lower the amount you pay out-of-pocket for deductibles, copays and coinsurance. The cost sharing reduction will get you more coverage for the best price.

5. Free, online tools can help. The Get Covered Plan Explorer is a new online tool designed to help families estimate out-of-pocket costs in Marketplace plans. Users enter basic information about the health and health care needs of each family member, as well as preferred doctors and hospitals, and receive a free, personalized estimate of out-of-pocket costs for all the Marketplace plans in their area. Users can then filter to see only plans that accept the doctors, hospitals, and other providers they want and need.

6. Free, in-person help is available in your community. Maybe you would prefer to talk face to face with a trained, unbiased assister in your community who can answer your questions and help you through the enrollment process. Good news! Free local help is available, and you can look up assisters and schedule an appointment using the Get Covered Connector.

Did you use the Get Covered Plan Explorer tool and/or the Get Covered Connector? Enroll America would love your feedback! Send any suggestions to

Jennifer Sullivan is the Director of the Best Practices Institute at Enroll America, the nation’s leading health care enrollment coalition. An independent nonprofit, nonpartisan organization, Enroll America works with more than 4,600 partners in all 50 states and the District of Columbia to create cutting-edge tools, analyze data, inform policy, and share best practices in service of its mission: maximizing the number of Americans who enroll in and retain health coverage under the Affordable Care Act.


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