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Wednesday, March 19, 2014

Helping Consumers Pick a Health Plan That Will Meet Their Needs

Elaine Saly

Health Policy Analyst

Enrollment workers wear many hats, but one of the most important aspects of their job is helping consumers choose a plan that meets both their financial and health care needs. With all the different variables involved, it can be a daunting task. To help, our Enrollment Assister Network held a webinar to discuss how to help consumers understand and compare health plans.

When helping consumers select a health plan from the marketplace, it is important to not just ask questions, but to ask the right questions. Does the consumer have any special health care needs or disabilities? Is he or she interested in dental coverage? Are there specific doctors he or she wants to visit? All of these questions can help an enrollment assister explain health plan options effectively to help consumers pick the health plan that will best fit their financial and health care needs. 

Jessica Kendall, Director of the Enrollment Assister Network at Families USA, moderated the panel, which included my own insights, as well as insights from three health plan selection experts: 

  1. Karl Cooper, Project Associate, The National Disability Navigator Resource Collaborative at the American Association on Health and Disability
  2. Colin Reusch, Senior Policy Analyst, Children's Dental Health Project and 
  3. Olga Semenova, Jewish Family Service, Michigan

Colin Reusch reviewed important information about buying children’s dental coverage through the marketplace. Karl Cooper explained how to help consumers with disabilities review plan information and identify health care needs. And Olga Semenova, a certified marketplace navigator, discussed how she helps consumers understand their health plan options.

Frequently Asked Questions

In addition to the informative presentations, we received many questions that we were unable to answer during the webinar. Below you will find answers to the most frequently asked questions:

Q:    Does cost-sharing (copays, co-insurance, or deductibles) apply to services that are considered essential health benefits?

A:    All marketplace health plans must cover certain health care services that are considered essential health benefits, however cost-sharing for these services will vary depending on the plan. Check the plan’s Summary of Benefits and Coverage for information about copays, co-insurance, and deductibles. When assisting consumers who are eligible for cost-sharing reductions, make sure that the plan’s Summary of Benefits and Coverage provides the right cost-sharing prices. If a consumer is eligible for lower cost-sharing and this reduction is not reflected in the Summary of Benefits and Coverage, or if you have questions about coverage for specific services, it is important to call the health plan to ensure you have all the information you need.   

And remember, all marketplace health plans must provide certain preventive health services without charging copays or co-insurance, even before you pay the deductible for the health plan. provides a list of preventive services that must be covered at no cost.

Q:    Can premium tax credits be used to lower the cost of buying a stand-alone dental plan?

A:    Yes. If the consumer has some of his or her premium tax credit left over after it is been applied to a medical plan, then this amount can be used to lower the cost of a stand-alone children's dental plan. Families USA’s fact sheet Buying Children’s Dental Coverage through the Marketplace provides important information about comparing the cost of buying a health plan that includes children’s dental coverage versus the cost of buying a medical plan and a separate plan that provides children’s dental coverage.

For states that have a federal marketplace, premium tax credits that are leftover after purchasing a medical plan cannot currently be used to lower the cost for a separate adult dental plan. State that are running their own marketplaces may allow leftover premium tax credits to be used for separate dental plans. 

Q:    What is the difference between basic and major dental care benefits?

A:    Basic dental care benefits include:

  • Basic services such as relatively easy restorative treatments like fillings, simple extractions, and periodontal treatments. Preventive/diagnostic services typically refers to checkups, cleanings, x-rays, and fluoride treatments. 

Major dental care benefits include:

  • Major services such as more advanced procedures like surgical extractions, root canals, dentures, and dental implants. 

Specific dental services may vary slightly from plan to plan in terms of how they are categorized. It is important to review a plan’s Summary of Benefits and Coverage to find information about covered dental benefits.

Q:    Can a consumer who is not eligible to enroll in a marketplace health plan still buy a stand-alone dental plan?

A:    Yes, however, consumers who want to purchase only a dental plan will need to enroll in the dental plan by directly calling the insurance carrier that offers the plan. You can use the plan browsing tool on to get information about available dental plans.

Q:    What happens if a person becomes disabled and has to change his or her health plan?

A:    If this situation occurs during open enrollment, then making a change can be done as it would with any other health plan. However, if it is not during open enrollment, then the onset of a disability does not trigger a special enrollment period. It should be noted that if the onset of the disability causes the loss of a job and health coverage through that job, then this would qualify the individual for a special enrollment period. Also, the individual may be able to enroll in Medicaid based on his or her disability. Medicaid allows for year-round enrollment.

March 31, 2014 marks the end of the first open enrollment period. So far, it’s proved to be a great success, and the thousands of diligent enrollment workers deserve much of the credit, as they have spent hours working with consumers across the country to get people in enrolled in affordable, high-quality health coverage—many for the first time. 

We hope these resources make your job a little bit easier.