Buying your own plan on HealthCare.gov: when to do it alone and when to get help

Yes, you can, and for some people it is the right call

Yes. Anyone eligible can shop and enroll in a Marketplace plan on HealthCare.gov without an agent, during open enrollment or after a qualifying life event. Doing it yourself works well when your situation is simple and you check your doctors and prescriptions against each plan before you choose. An agent or broker helps most when your income is hard to predict, your household is complicated, or you have ongoing care you cannot afford to have disrupted. Using a licensed agent or broker does not raise your premium.

I am Rex Slover of Slover Agency in Murphy, and I help self-employed people, early retirees and families between jobs with individual coverage across the Dallas area. I would rather you enroll correctly on your own than enroll badly with help, so this guide gives you the checks I would run if I were sitting next to you.

Situations where going it alone usually works

Some households are straightforward. If you recognize yourself here, the HealthCare.gov tools will probably get you to a sensible plan, as long as you take the time to look past the premium.

• A single person or couple with steady, predictable income
• No ongoing specialist care and no expensive regular prescriptions
• No strong attachment to a particular doctor or hospital
• You are renewing a plan that worked well last year
• You are comfortable reading a plan summary and comparing deductibles and out-of-pocket limits

Situations where help pays for itself

Other households have more moving parts. Self-employed people are the classic example: the savings you may qualify for are based on the income you estimate for the year, and if your income swings, so does the math. A wrong estimate can mean a different subsidy than you expected, which is a conversation to have with your tax preparer as well as your agent.

Families with a member who has a chronic condition, people managing several specialists, and anyone whose prescriptions are expensive should get help or at least a second set of eyes. The difference between two plans for these households is rarely the premium. It is whether the specialist is in network and where the medications fall on the drug list.

The same goes for households in transition. If one spouse is about to start a job with benefits, or someone is turning 65 next year, the right plan for the next twelve months may be different from the one that looks best on paper, because you may only need it for part of the year.

• Self-employed or commission income that changes month to month
• A household member with ongoing treatment or several specialists
• Expensive or specialty prescriptions
• Mixed coverage in one family, such as one spouse on an employer plan
• Someone approaching 65 who will move to Medicare soon

Five terms to understand before you compare anything

Plan pages are full of numbers, and most confusion comes from a handful of terms. Once these are clear, comparing plans becomes arithmetic instead of guesswork. The out-of-pocket maximum deserves the most attention, because it tells you the worst year you could have on that plan for covered, in-network care.

A useful exercise is to take your top two plans and write out three years side by side: a quiet year with only checkups, a typical year for your household, and a bad year that reaches the out-of-pocket maximum. The plan that wins two of those three is usually the right one for you.

• Premium: what you pay every month, whether or not you use care
• Deductible: what you pay for covered services before the plan starts sharing costs
• Copay: a flat amount for a visit or prescription, often before or regardless of the deductible
• Coinsurance: your percentage of the bill after the deductible
• Out-of-pocket maximum: the most you pay in a year for covered in-network care

If you enroll yourself, do it in this order

The Texas Department of Insurance's health coverage guide recommends comparing several plans, checking that your doctors and medications are covered, and filling out your application accurately, since leaving information out on purpose can lead to canceled coverage or denied claims. Here is how I would turn that into a routine.

Give yourself an evening for this, not ten minutes on a lunch break. The comparison is where the value is, and rushing it is how people end up with a plan that looks cheap and works badly.

• Write down your doctors, the hospital you would want to use, and every regular prescription with its dose
• Gather income information for everyone in your tax household and make your best estimate for the coming year
• Filter plans by your doctors first, then by your prescriptions, and only then by premium
• For your top two or three, compare the deductible, coinsurance and out-of-pocket maximum, not only the monthly price
• Estimate a realistic year of care on each finalist, including one bad month
• Answer every application question accurately, then save your confirmation and plan documents

Dates to put on the calendar now

HealthCare.gov lists Open Enrollment as November 1 through January 15. To have coverage start on January 1, you need to enroll or change plans by December 15. If you miss January 15, you generally have to wait for the next Open Enrollment unless a life event opens a Special Enrollment Period for you.

If you already have a Marketplace plan, do not assume renewing is the right move. Plans, networks and drug lists can change from year to year, so the plan that fit this year deserves a fresh look before December 15.

• November 1: Open Enrollment begins
• December 15: last day to enroll for coverage starting January 1
• January 15: Open Enrollment ends

What an agent or broker can and cannot do for you

HealthCare.gov describes an agent or broker as a trained insurance professional who can help you enroll, and it notes that you will not pay anything additional if you enroll through one, because insurers typically pay them commissions. It also says some may not sell plans from companies they do not represent, so ask which carriers the person works with.

One rule matters a lot: to get savings such as the premium tax credit through an agent or broker, they must enroll you through the Marketplace. If someone offers you a plan that is not on the Marketplace, ask directly whether you will lose savings you would otherwise qualify for, and whether the plan is full major medical coverage at all. My checklist for vetting anyone, including me, is in questions to ask a health insurance broker.

Networks around Dallas: the check most people skip

TDI explains that HMO and EPO plans generally require you to use in-network providers except in emergencies, while a PPO lets you go out of network at a higher cost. Many individual plans are HMOs or EPOs, which means the network is not a detail. It decides whether your care is covered.

In a large metro area, two plans from different carriers can include very different hospital systems and physician groups. Before you enroll, search each finalist's provider directory for your doctors by name, then call the doctor's office and ask whether they accept that specific plan, not just that carrier. Directories are not always current, and the office will know.

This matters more in the Dallas area than people expect, because the metro is large and spread out, and the hospital near your home may be in one carrier's network and not another's. If you have a child who sees a pediatric specialist, or you are planning a surgery or a pregnancy in the coming year, make the network check first, before you look at a single price.

Shopping outside Open Enrollment

HealthCare.gov explains that outside Open Enrollment you can enroll only if you qualify for a Special Enrollment Period. Losing qualifying health coverage is one of the most common reasons, and you may qualify if you lost coverage in the past 60 days or expect to lose it in the next 60. Marriage, a new baby and adoption are other examples. You may be asked to send documents confirming the event.

If you just lost a job, the order of decisions matters, and I walk through it in health insurance options after losing a job. If you are tempted by a cheaper plan that is not on the Marketplace, read the health plan mistakes I see every enrollment season first.

Where I fit if you want a second opinion

Some people come to me after they have already narrowed it down to two plans and want someone to check their reasoning. Others want me to do the whole comparison. Either is fine. I ask about your doctors, prescriptions, income and budget, compare plans across carriers, and explain the trade-offs in plain language.

I also look at what sits around the medical plan. Dental and vision coverage, life insurance and disability income protection are easy to forget when you lose an employer plan, and for a self-employed person, a disability policy can matter as much as the health plan itself. We can talk about those in the same conversation, or not at all if the health plan is all you need right now.

If you would rather enroll yourself after we talk, that is your choice, and I will tell you what to watch for. If you want me to handle it, I will, and you can call me during the year when a bill or a claim does not look right. Either way, the service costs you nothing, and the premium is the same as it would be if you enrolled on your own.

Questions people ask me