Purchasing health insurance has gotten much easier with government enrollment and insurance brokers. But, the technical jargon can still be confusing—case in point: off-exchange health insurance.
Read this article to learn about off-exchange health insurance, its pros and cons, who would benefit from it, and what you need to qualify. Use this guide to make an informed choice regarding your health insurance and to improve your quality of life.
What Is Off-Exchange Health Insurance?
To understand off-exchange insurance, you need to know what on-exchange health insurance is.
Under the Affordable Care Act, each US state has a health insurance exchange that offers more affordable health insurance options.
On-exchange insurance is insurance you buy directly from the government health insurance exchange.
Private insurance plans that you can buy directly from a licensed broker or insurance carrier are off-exchange plans. You cannot buy them on the government insurance marketplace. The plans are typically similar to on-exchange health insurance, with only minor differences like tax cuts and credit eligibility.
Off-exchange insurance is held to state and federal health insurance qualifications just as on-exchange health insurance is. However, plans are subject to state health insurance stipulations. For example, the same off-exchange health insurance plan could cost something different in Texas and California.
Advantages Of Off-Exchange Health Insurance
Off-exchange health insurance offers members some notable benefits.
- Greater plan options: Off-exchange plans often provide a wider range of options than those available on the exchange. This can be beneficial if you have specific healthcare needs or preferences that aren’t met by the plans offered on the exchange.
- Flexibility: Off-exchange plans can be more flexible regarding plan design and coverage options. This can allow you to tailor your coverage to match your needs and preferences better, for example, child-only health insurance.
- Access to more providers: Some off-exchange plans provide access to a larger network of healthcare providers and specialists, which can be important if you have established relationships with specific doctors or hospitals.
- Specialized plans: Some insurance companies offer specialized off-exchange plans that cater to particular demographics or health conditions, providing more targeted coverage options.
- Stability: Off-exchange plans may offer more stability regarding plan availability and coverage. They are not subject to the same yearly changes and limitations the exchange marketplace imposes.
Disadvantages Of Off-Exchange Health Insurance
These are the most notable disadvantages of off-exchange health insurance.
- Ineligible for subsidies: You cannot apply for cost-sharing or premium subsidies with off-exchange health insurance.
- No tax credits: Because most off-exchange buyers are above a certain income bracket and aren’t purchasing from the ACA marketplace, they aren’t eligible for tax credits.
- More expensive: Because off-exchange health insurance is bought directly, i.e., without government subsidies or lowered rates, they tend to be more expensive than on-exchange health insurance.
How To Choose An Off-Exchange Health Insurance Plan
Choosing a health insurance plan takes careful consideration. These key points will help you choose the best option for your needs and budget.
Consider Your Needs
When choosing health coverage, consider your individual needs, including dependents, budget, and any disabilities.
This will guide you in selecting the best off-exchange insurance plan, whether you require basic or comprehensive coverage with pediatric or specific insurance for a condition.
Cost Of Off-Exchange Health Insurance
The average cost of off-exchange employer-sponsored health insurance is $7,911 for individuals and $22,463 for families per year.
Individual plans for people who don’t have access to employee insurance average $5,472 annually.
You can use this average to determine the fair insurance offers that match the national average.
Another thing to consider when calculating insurance costs is the fees beyond your monthly premium:
- Deductibles: This is the amount you must pay before your insurer covers your healthcare costs. Deductibles are higher for off-exchange health insurance, especially for those paying for insurance without employer-sponsored insurance.
- Co-pays: The flat rate you owe after the deductible. For example, your insurance could charge a $15 co-pay for all GP visits.
Both these costs have a significant influence on your health insurance costs. If the deductible and co-pay are too high, we suggest looking for a more affordable health insurance option.
Check The Health Insurance Networks
Make a list of the types of medical professionals you and your family might need to visit in any given year. Then, look at the off-exchange health insurance provider’s network options.
Do they have in-network options for your healthcare needs? Are the co-pays high? Are they located close to where you live? Do the hospitals, clinics, or practices have the equipment and expertise for what you need? Do they have good reviews?
If the off-exchange insurer doesn’t have high-quality networks offering what you need, look for one worth your premium.
Qualifying For Off-Exchange Health Insurance
Qualifying for off-exchange health insurance typically involves meeting certain eligibility criteria set by insurance providers and government regulations.
The specific requirements can vary depending on the insurer and your location, but here are some general factors that may impact your eligibility for off-exchange health insurance:
- Residency: You usually need to be a resident of the state where you seek to purchase the insurance. Insurance regulations and options can differ from state to state.
- Age: Insurers often have minimum and maximum age requirements for their plans.
- Citizenship/Immigration Status: In the United States, eligible individuals must be U.S. citizens, nationals, or lawfully present immigrants to purchase off-exchange health insurance.
- Income: Off-exchange plans are not subsidized like plans on the Health Insurance Marketplace. Your income might still be relevant to determining your eligibility for certain plans or calculating your premium.
- Enrollment Periods: Off-exchange plans are generally subject to the same open window enrollment period as on exchange plans unless you qualify for a Special Enrollment Period.
Types Of Off-Exchange Health Insurance Plans
Point Of Service (POS) Insurance
With Point Of Service insurance, the most affordable option is using the plan-approved healthcare network. You must choose an in-network primary care doctor and get referrals from that doctor for specialist visits.
With POS insurance, you can also choose to visit providers outside your network. However, visiting an out-of-network provider will include a higher fee and a separate deductible.
Exclusive Provider Organization (EPO)
Exclusive Provider Organizations only cover in-network visits. If you go outside the provider network, you are liable for medical costs. The only time the EPO will cover the out-of-network costs is if it is an emergency.
Preferred Provider Organization (PPO)
Preferred Provider Organizations offer more network freedom. You don’t need a primary care provider, and you can visit both in and out-of-network medical professionals. Of course, you’ll pay less for in-network visits.
For this increased freedom, your coverage will be more than it would be for POS and EPO insurance.
Health Maintenance Organization (HMO)
Health Maintenance Organizations provide a network of medical professionals with lower co-pays. You need a referral to see a specialist. While HMOs tend to be more affordable, you are responsible for covering the total cost of out-of-network visits. This is an affordable health insurance option if you stay within your network.
How To Enroll In An Off-Exchange Health Insurance Plan
Enrolling in off-exchange health insurance involves a series of steps, which can vary depending on the insurance provider and your location. Here’s a general guide on how to enroll in off-exchange health insurance:
- Research and Compare Plans: Research different insurance providers and their plans. You can visit the websites of insurance companies operating in your state to explore their plans.
- Contact Insurance Companies: Once you’ve identified a few insurance plans you’re interested in, contact the insurance companies directly. You can do this by visiting their websites, calling their customer service numbers, or visiting their local offices.
- Provide Information: When you contact the insurance company, you must provide personal information such as your name, address, date of birth, and any other information required for enrollment.
- Application Process: The insurance company will guide you through the application process. This may involve filling out forms online, over the phone, or in person. Be prepared to provide detailed information about your medical history, pre-existing conditions, and preferred coverage options.
- Submit Documentation: Depending on the plan and the insurance company’s requirements, you may need to submit certain documents to verify your eligibility. This could include proof of residency, citizenship/immigration status, and other relevant documents.
- Choose Your Plan: Based on the information you provide and your preferences, the insurance company will present you with plan options that are available to you. Review the details of each plan carefully, including the coverage, costs, and network of healthcare providers.
- Pay Premium: If you decide to move forward with a specific plan, you must pay the first premium to initiate your coverage. The insurance company will provide premium payment methods and deadlines.
Use Health Insurance Experts
Insurance representatives, brokers, and agents like our team at Enhance Health can help you navigate health insurance complexities and find the right plan based on your needs.
We provide personalized assistance and access to multiple insurance companies. At Enhance Health, we ensure you get the most for your premium and choose the right insurance type.
Off-exchange is insurance that is not purchased from the government insurance exchange.
Besides not having access to tax credits and subsidies, it’s not much different from on-exchange insurance. It also offers several benefits, including more insurance tiers, cover options, and straightforward enrolment.
If you’re still overwhelmed by health insurance, call Enhance Health today. We champion affordable health insurance by providing access, support, and education to all things health insurance.