The Affordable Care Act (the “ACA”) has completely changed the landscape for health insurance.  A major reduction in health coverage exchange options has occurred, and every year more companies are dropping out of states.  This is not the intention the ACA planned for, however it is the current reality.

According to the Department of Health and Human Services, 85% of the individuals that shop on the federal or state exchanges qualify for subsidies.  This gives many people the ability to afford health insurance, but still leaves a significant amount of people paying more than they need to.  This begs the question: if you make enough money so you no longer qualify for subsidies, what do you do?


When you don’t qualify for subsidies, an off-exchange plan is likely the best course of action.  There are many more options than an Exchange plan for you that will offer varying prices and different benefits when you go this route.

The classification for the value of these plans is: bronze, silver, gold, and platinum.  Because of the diversity in off-exchange plans, the values within each tier differ based on the plan.  Silver plans tend to be the most popular choice.

Buying off-exchange coverage can become a complicated process because of all the options.  Typically, the most important factors to customers are the premium cost and the out-of-pocket cost, while the network is glossed over.  Be careful not to ignore any areas, especially the network because it can be cost you later on.  Going outside of your network typically leaves you with a majority, if not all, of the medical bill.  This also does not count towards your deductible or out-of-pocket limit.

If you have a chronic illness, consider getting a plan with higher premiums because a larger section of your medical bills will be covered.  This also means you will have lower deductibles, so you will pay less at the start before insurance covers most, if not all of the rest of the costs.

Another feature of not going through an Exchange plan is the lists of medications that can be prescribed.  Some specialty drugs are not covered by the Exchange plans, so you can look for a plan that would cover it outside of the Exchange.  Keep in mind that a reason a particular drug wouldn’t be covered by the Exchange plan is its high cost, so you may have a plan with high premiums to have it covered.

How to Approach an Off-Exchange Purchase

Once you know that you are not qualified for subsidies, the process of finding insurance elsewhere is intimidating.  Begin by exploring insurers’ websites for comparison, which can be done easily through an independent plan-comparison website.  A more personal option is to hire a broker who is licensed in both non-exchange and Affordable Care Act plans.  They can find the right option for you without being biased.

ACA plans are not always the best option for individuals because paying for insurance without any subsidies is an expensive venture.  Exploring other options in the off-exchange market will broaden your possibilities, but note that you will only be able to obtain subsidies for healthcare coverage if you go through an Exchange.

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