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Tips for Navigating Marketplace Health Insurance Plans

Open enrollment begins in November for coverage starting in 2015.

The Affordable Care Act – otherwise known as “Obamacare” – has ushered in many changes to health insurance coverage. For one thing, many Americans can now buy subsidized health insurance plans through state or federally run exchanges. But not all plans are the same.

Open enrollment for these plans begins soon. Experts at Shepherd Center are offering timely tips to help navigate the process if you are planning to buy or change plans.

The Basics

Good health coverage is important to stay healthy and get the best treatment. Health insurance exchanges are designed for two main groups of people – those who either don’t have insurance or currently purchase their own insurance (not through an employer).

Plans vary by state and there are also different categories or metallic levels ranging from bronze to platinum – each of which will pay less or more of your costs when you need care. These plans have different monthly premiums, deductibles, coinsurance amounts and out-of-pocket expenses. Your income, age, the state in which you live and the size of your family will factor into how much you will pay.

Plan Type What the Plan Pays
Platinum 90%
Gold 80%
Silver 70%
Bronze 60%


Catastrophic care plans are also available for certain enrollees and can protect against very high medical costs; they act as a safety net in the event of an accident or serious illness. This plan is typically available to people under 30 or those under a certain income level.

In addition to expanding healthcare coverage for the uninsured, the Affordable Care Act also addresses many of the problems with health insurance coverage, including exclusions for pre-existing conditions, lifetime and annual limits, right to cancel insurance policies (right of rescission), and poor benefits and coverage in individual health plans.

“The government also came up with ‘essential health benefits,’ so all [the qualified health] plans offered on the Healthcare Marketplace would have similar and reasonable benefits for consumers,” explained Mitch Fillhaber, senior vice president of corporate development and managed care. Rehabilitation and habilitation services to gain or regain skills or independence (e.g., speech and language, occupational and physical therapy, aids and devices) are included as one of the 10 Essential Health benefits.

10 Essential Benefits of Healthcare Marketplace Insurance Plans
ambulatory patient services
emergency services
laboratory services
maternity and newborn care
mental health and substance abuse services
prescription drugs
rehabilitative and habilitate services and devices
prevention and wellness services and chronic disease management
pediatric services, including oral and vision care

“People who sign up via a health exchange are ensured some type of rehabilitation benefit,” said Fillhaber, adding this is a big step forward. “It was always hit or miss so this is much better in terms of standardizing benefits.”

Still, the plans offered will have differences in:

  • Covered services/types of treatment
  • Which providers or hospitals are covered
  • What is deemed “medically necessary”
  • Treatment limits (number of visits, lengths of hospital stay, etc.)

Practical Tips

If you are thinking about buying a plan on the exchange, Fillhaber said you may want to:

  • Do your own investigating. Visit to find answers to commonly asked questions, learn about the plans for which you are eligible and to use the subsidy calculator tool.
  • Find out whether your preferred hospital and healthcare providers are in-network by scanning the plan’s list of providers. You may want to double check with your hospital’s or physician’s business office to confirm they are participating in the plan. Because the trend is toward narrow networks, ask yourself if you are willing to trade choice for price.
  • Know your benefits and what you can afford. Print out the summary of benefits for the plans you are considering and compare what is covered and estimate out-of-pocket expenses. Individuals and families with incomes between 100 and 400 percent of the federal poverty level are eligible for subsidies for premiums. There are also new ceilings on out-of-pocket expenses to protect individuals from high costs, but these may only apply to in-network benefits.
  • Use assistance programs. These programs are free and can provide objective research and advice. For Georgians, check out Georgians for a Healthy Future ( or the University of Georgia College of Family and Consumer Sciences (
  • Make sure the pricing is still competitive for the health services you are already receiving if you are already enrolled.
  • Call health plan customer service lines to verify online information.

Planning for the Worst Case

So, how much coverage is enough in the event of a traumatic injury? Fillhaber explained the more severe the accident or illness, the more time and services would be required.

“At Shepherd Center, patients with acquired brain and/or spinal cord injuries average between 30 to 60 or more days before moving on to a day or outpatient program either in Atlanta or back in their local community,” he said.

Some plans have exceptions for costly illnesses or injuries that weren’t anticipated or that exceed the capabilities of the current network. For this reason, Fillhaber encourages patients to request Shepherd Center in the event of a catastrophic occurrences.

“It gives us the opportunity to negotiate an exception with that health plan and hopefully care for that patient,” he said. “Some of the networks are narrow, so we are doing our best to reach out to all exchange providers to identify what it would take to participate in their networks.”


Open enrollment begins Nov. 15 and runs through mid-February.

There are four ways to sign up for your state's Health Insurance Marketplace.

1) Find your state's marketplace website.

2) Get in-person help. You can find in-person help by going to

3) Call the 24/7 Marketplace helpline at 1-800-318-2596.

4) Mail in a paper application.

About Shepherd Center

Shepherd Center provides world-class clinical care, research, and family support for people experiencing the most complex conditions, including spinal cord and brain injuries, multi-trauma, traumatic amputations, stroke, multiple sclerosis, and pain. An elite center recognized as both Spinal Cord Injury and Traumatic Brain Injury Model Systems, Shepherd Center is ranked by U.S. News as one of the nation’s top hospitals for rehabilitation. Shepherd Center treats thousands of patients annually with unmatched expertise and unwavering compassion to help them begin again.