Step 3 – Picking the Type and Level You Want

Health insurance plans are designed differently to offer more benefit options for different prospective members. You must understand the basic terminology in Health Insurance 101 and have a good idea of your financial picture to effectively select the right type of plan for you or your family.

The main types of plans are:

Copay Plans – Often referred to as traditional plans, copay plans have a copay for a primary care or specialist doctor visit. Typically all other costs excluding prescription medications go towards the deductible. Once the participant hits the deductible coinsurance kicks in until he or she reaches the annual maximum-out-of-pocket. After the participant reaches the max-out-of-pocket number the insurance company pays 100% of the medical expenses incurred for the remainder of that calendar year. Copay plans can be designed without a deductible. Every plan except for catastrophic plans (see below) must offer at least some coverage for brand name prescription medications.

Health Savings Plans (HSA’s) – Health Savings Accounts are not an actually type of health plan. They are tax-advantaged savings accounts similar to a traditional savings account. Instead of being taxed like a traditional savings account, the HSA’s aren’t taxed as long as the participant only uses the funds for qualified health expenses. Using the funds for anything other than a qualified medical expense also results in an additional tax penalty. In order to open and contribute into a HSA, one must have a High Deductible Health Plan (HDHP). Every year the limits for what qualifies as a HDHP move up with inflation. As of 2014 plans that do not pay for any expenses until the plan participant has paid the first $1,250 can qualify to be HDHP’s.

Health Reimbursement Plans (HRA’s) – With Health Care Reform, HRA’s can only be offered through an employer. Similar to an HSA, a HRA is not an actual type of health plan. Insurance companies do design specific plans where the employer can cover a portion of the medical expenses over a certain amount by reimbursing the employee only after incurred expenses. The advantage to offering a plan like this to employees is to reduce the premium charged by the insurance company and reduce the potential out-of-pocket cost for the employees.

Self-Funded Plans – The most common type of plan for large employers, being self-funded means just that. A self-funded plan typically results in more flexibility and lower health care costs for employers. Plans can be customized and designed how ever the employer wants. With most plans the employer will buy Stop Loss insurance to cover claims over a certain amount for both individual and aggregate. The amount of savings depends on the health of the group. Typically there are good claim years and bad claim years which level out over a large group, however, smaller groups might be at high risk for loss.


The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 23rd, 2010 to regulate the health insurance marketplace in the United States. The new law mandated that everyone must have a Qualified Health Plan (QHP). As a result, insurance companies had to redesign their plans to comply with the law. All health insurance plans in place prior to March 23rd, 2010 have been accepted under the new law as Grandfathered Plans. All health insurance plans designed after March 23rd, 2010 had to be modified to include various attributes like the essential health benefits, the new actuarial medal levels, and new medical loss ratios. Unless you have a Grandfather Plan,  you will be forced into a new QHP.

With health care reform, all health plans were mandated to cover these 10 essential benefits:

  1. Outpatient care—the kind you get without being admitted to a hospital
  2. Trips to the emergency room
  3. Treatment in the hospital for inpatient care
  4. Care before and after your baby is born
  5. Mental health and substance use disorder services: This includes behavioral health treatment, counseling, and psychotherapy
  6. Your prescription drugs
  7. Services and devices to help you recover if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.
  8. Your lab tests
  9. Preventive services including counseling, screenings, and vaccines to keep you healthy and care for managing a chronic disease.
  10. Pediatric services: This includes dental care and vision care for kids


The benefit levels are defined by the actuarial values (what percentage of costs they cover). The range from bare bones coverage to almost all inclusive. Typically the plans ranging from Bronze to Platinum have the following characteristics…

1. Catastrophic – only available to individuals under the age of 30, very high deductible, no copays or drug coverage, annual max-out-of-pocket of $6,350

2. Bronze – covers 60% of costs, copay for first 1 or 2 visits, all other costs go to a high deductible including brand name drugs, $6,350 max-out-pocket

3. Silver – covers 70% of costs, office visit copay’s, mid-level deductibles, first dollar coverage for certain brand name drugs, $6,350 max-out-of-pocket

4. Gold – covers 80% of costs, lower office visit copays, mid-to-low deductible with lower than $6,350 max-out-of-pocket, first dollar brand drug coverage

5. Platinum – covers 90% of costs, lowest copays, deductible, and max-out-of-pocket, strong brand name drug coverage, not offered by most insurance companies

After deciding what type of plan you want, price becomes the final consideration. Call us now at 720-708-3474 to have a local expert quote you!


Figure out where to quote and apply depending on your location and eligibility for a tax credit. Please  see Step 4 – To Apply On Exchange or Off Exchange.

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