One of the most important parts of the plan shopping process is identifying what a consumer actually needs.
In this article we'll cover:
Understanding consumer needs
There are four main elements that help differentiate one plan from another: providers, prescriptions, usage, and budget.
Asking questions helps agents understand the consumer’s priorities and how they expect to use their coverage. Identifying those priorities before plan shopping makes it possible to narrow plan options in a meaningful way.
Providers
A provider is a doctor, hospital, or other healthcare professional or facility that provides medical care. Carriers contract with groups of providers to form networks, and those networks determine which providers will be covered by a plan.
Network types
The type of network a plan uses typically dictates the level of flexibility a consumer has when accessing care.
Common network types include:
Preferred Provider Organization (PPO): Consumers typically pay less when they use in-network providers. A referral is typically not required to see a specialist, and out-of-network care may be covered at a higher cost.
Point-of-Service (POS): Consumers typically pay less when they use in-network providers. A primary care provider (PCP) usually coordinates care, and a referral is typically required to see a specialist. Out-of-network care may be covered at a higher cost.
Exclusive Provider Organization (EPO): Coverage is typically limited to in-network providers, except for emergency care. Referrals are typically not required.
Health Maintenance Organization (HMO): Coverage is typically limited to in-network providers, except for emergency care. A primary care provider usually coordinates care, and a referral may be required to see a specialist.
Plans with greater network size and flexibility often carry higher premiums.
Network rules and provider participation can change and vary by carrier and plan. Agents should review the carrier’s current provider directory and work directly with the carriers they are appointed with to understand the specific details of each network.
Prescriptions
Carriers can offer different lists of covered prescription drugs, called formularies.
Formularies
A formulary specifies which medications are covered by a plan and how they are covered. A formulary typically includes:
The names of covered prescription drugs
How the plan categorizes each prescription (for example by tier)
Coverage rules and restrictions (for example prior authorization, quantity limits, and step therapy)
Information about specialty pharmacies and mail order pharmacy options
Formularies can vary plan to plan, network to network, and carrier to carrier. A medication covered under one plan from a given carrier is not guaranteed to be covered under all plans that carrier offers.
Usage
Usage has a direct impact on the benefits a consumer is likely to value. Upcoming procedures may be known, services and visits may be anticipated, or low plan usage may be expected.
It can be useful to think of anticipated usage in three general categories:
High usage: The consumer has known upcoming procedures, chronic conditions, or expects regular provider visits.
Moderate usage: The consumer expects occasional provider visits or has unpredictable needs.
Low usage: The consumer is mainly seeking coverage in case of an emergency.
Understanding where a consumer falls helps identify which plan features matter most and where concessions can be made when balancing benefits against cost.
Affordable Care Act (ACA) plans cannot deny coverage, charge a higher premium, or exclude essential health benefits because of a pre-existing condition. Anticipated plan usage does not affect whether a consumer can enroll in a plan.
Budget
A plan with the lowest monthly premium is not always the most affordable option over the course of a plan year.
Agents often find it useful to lead with providers, prescriptions, and usage before turning to budget. Monthly cost is an important consideration for many consumers, but what a consumer values and how the consumer expects to use coverage affect the plan’s overall affordability.
When discussing budget, review the different costs a consumer may be responsible for during the plan year.
Costs to consider
Possible costs a consumer may be responsible for include:
Monthly premium: The amount a consumer pays each month to maintain coverage, regardless of whether the plan is used.
Deductible: The amount a consumer pays for covered services before the plan begins to pay. A deductible may not be required for all services.
Copayments (copays) and coinsurance: Fixed dollar amounts (copays) or set percentages (coinsurance) a consumer pays each time they receive a covered service. These amounts may apply before or after a deductible is met, depending on the plan.
Out-of-pocket maximum: The most a consumer will pay for covered, in-network care in a plan year. After this amount is reached, the plan covers 100% of costs. Deductibles, copayments, and coinsurance that the plan counts generally apply toward the out-of-pocket maximum. Monthly premiums, non-covered services, and most out-of-network costs do not.
Possible costs reset each plan year. They may also reset if a consumer changes plans during the plan year, which is important to communicate to consumers who are considering a mid-year plan change.
Plans that include out-of-network benefits may track out-of-network costs separately.
Metal levels and cost sharing
ACA health plans are categorized into metal levels that reflect how costs are shared between the consumer and the carrier.
Consumers who expect to use their benefits frequently may find that a plan with a higher premium and lower out-of-pocket costs results in lower total spending for the year. Consumers who anticipate low usage may prefer lower premiums and accept a higher share of costs if they need care. Metal levels help articulate these trade-offs clearly.
Discovery questions
Plan results can be filtered to narrow options based on the consumer’s needs.
Ask the consumer questions to better identify their priorities and how they expect to use coverage.
Providers
The following questions can help agents understand a consumer's provider preferences before shopping:
Are there any specific providers you want to be able to access?
How important is it to have access to those providers?
Do you travel outside of your area often?
Are you okay with needing a referral before seeing certain providers?
Prescriptions
The following questions can help agents identify a consumer's prescription coverage needs:
Do you take any prescriptions?
Do you take the brand name or the generic version?
What dosage do you take?
How much do you get with each refill?
How often do you get refills?
Encouraging consumers to have their prescription bottles on hand during the conversation can be helpful, as exact prescription names, dosages, and quantities are important when reviewing a plan's formulary.
Usage
The following questions can help agents understand how a consumer expects to use their coverage:
Do you go to the doctor often or infrequently?
Do you have any upcoming procedures or treatments?
Do you expect to use the plan often, mainly for emergencies, or both?
Is there anything we haven't discussed that you'd like to prioritize?
Budget
The following questions can help agents understand a consumer's budget priorities:
Is there a maximum amount you can afford to spend on insurance monthly?
Would you rather pay more up front and less when you use the plan, or less up front and more when you use the plan?
Health Savings Account (HSA)-compatible plans allow eligible consumers to contribute to a separate HSA, which can be used for qualified medical expenses. Contributions may be excluded from or deducted from federal taxable income, and unused funds roll over year to year. Would you be interested in a tax-advantaged savings account you can use for medical costs?
Frequently asked questions
What are metal levels?
Affordable Care Act (ACA) plans fall into four different categories referred to as metal levels. Metal levels include Bronze, Silver, Gold, and Platinum plans. The main difference between each metal level is how costs for covered services are shared between the carrier and the consumer.
Catastrophic plans are also available to certain consumers.
Additional resources
For help using HealthSherpa or for other assistance, contact Agent Support. Agent Support is available by phone at (888) 684-1373, by email at Support@HealthSherpa.com, or by chat directly from your account.