Major Medical Plans
- What is my estimated net monthly premium after premium tax credits are applied?
- If my household income falls between 100% and 250% of the federal poverty level, how much would cost-sharing reductions improve the Silver plan's deductible and out-of-pocket maximum?
- Are my current doctors and preferred hospitals included in the plan's network?
- Are my current prescriptions listed on the plan's formulary, and at what cost tier?
- What is the plan's annual out-of-pocket maximum?
- Am I eligible for premium tax credits or cost-sharing reductions through the Marketplace?
- If I buy directly from an insurer, is the plan or network meaningfully different from what is available on the exchange?
- Are the benefits, provider network, and formulary identical between the Marketplace and direct-purchase versions of this plan?
- Does this plan satisfy my state's individual mandate, if one is in effect?
ICHRA
- What is my monthly ICHRA allowance, and does it cover only premiums or also other qualified medical expenses?
- Is my ICHRA considered affordable under the applicable IRS affordability threshold for the plan year, or can I opt out and claim premium tax credits instead?
- What documentation do I need to submit to my employer for reimbursement, and how quickly are claims processed?
- If I decline the ICHRA, can I change my mind and accept it later, or is the decision locked for the plan year?
- Does my employer's ICHRA plan year align with the Marketplace Open Enrollment period?
- Does the plan I am considering qualify as minimum essential coverage, which is required to use ICHRA funds?
Temporary Coverage and Other Non-ACA Options
- Which essential health benefits does this plan exclude?
- Are my pre-existing conditions covered, or are they excluded from the policy?
- Is this plan renewable, and what are my state's specific rules on maximum duration?
- For health care sharing ministries, what is the sharing threshold, and what are the per-incident and annual caps on sharing?
- Does this plan or membership satisfy my state's individual mandate, if applicable?
- What is the claims or sharing reimbursement process, and how long does payment typically take?
Temporary coverage and other non-ACA products aren't ACA-compliant and don't meet Minimum Essential Coverage requirements.
Vision and Dental Plans
- Does my primary health plan already include any dental or vision benefits, such as pediatric dental coverage required under the ACA?
- What is the annual benefit maximum, and is it sufficient for the care I expect to need this year?
- Are there waiting periods before major procedures are covered, and if so, how long?
- Are my current dentist and eye doctor in the plan's provider network?
- What is covered for preventive care versus basic and major procedures, and what are the copay or coinsurance rates for each category?
- Does the vision plan provide a defined allowance for frames and lenses, or a discount-only benefit?
- If I need specialty care such as orthodontics or medically necessary contact lenses, is it covered or excluded?
Critical Illness, Accident, and Hospital Indemnity
- Which specific diagnoses or events does the policy cover, and which are excluded?
- Is the payout a one-time lump sum, a per-event benefit, or a daily amount, and how much is it?
- Can I receive a benefit more than once if I experience multiple qualifying events or a recurrence?
- Is there a waiting period or elimination period before benefits become payable?
- Are pre-existing conditions excluded, and if so, for how long?
- Can I keep this policy if I leave my employer, and does the premium change if I do?
- Are the premiums paid pre-tax or post-tax, and how does that determine whether the benefit I receive is taxable income?
Critical Illness, Accident, and Hospital Indemnity products aren't ACA-compliant and don't meet Minimum Essential Coverage requirements.