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I'm self-employed and it's open enrollment time. My current health insurance was bought on the state exchange but the premium is going up 22% so that certainly encourages you to shop around. I've found two plans that look better because although they have similar premiums, they are HSA-eligible, which I consider a major discount because I get the tax savings from contributing and will probably be able to spend the money tax-free on medical expenses later in life (not to mention the tax-free growth in between).

The first plan is on the state exchange, but it's with a different carrier, which would require me to change doctors. The second plan is with the same carrier, so I wouldn't have to change anything, but it's not on the state exchange. A plan that looks identical according to the specs, but with a slightly different name (Bronze HSA versus Bronze HSA X), is available on the exchange in other counties.

Why would a plan be offered on the exchange in some counties but not in others within the same state? What are the risks I should be aware of when purchasing insurance from outside of the exchanges? I am aware that I will be ineligible for the premium tax credit, but the odds that my income would be low enough to qualify are minimal anyway.

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2 Answers 2

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As far as I know, the exchanges are just a convenient, standardized marketplace that makes finding and comparing your options easier, and that vets the offers to make sure they meet basic requirements. If you think you can do better shopping on your own or working through an agent, I believe you are free to do so. (I went directly to a retiree plan sponsored by my ex-employer, without bothering to look at the exchanges; others were more diligent about comparing.)

Make sure whatever you pick meets the requirements for creditable coverage. Anything on the exchange should.

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I just got off the phone with my agent to talk about this and other things. I'm also self-employed, and I was concerned about how the subsidies work and getting bit by the claw back for years when I make too much.

He said there is no difference between buying on or off the exchange, unless you are qualified to get the subsidies. The exchange exists to verify who gets the subsidies. If you are shopping outside of the exchange, then you are foregoing the subsidy (if you qualified at all). This is the "you get to keep your insurance" part of the situation.

As for county specific plans, that probably has to do with the doctor network. That gets into the nitty-gritty of insurance payouts. You'll probably have to call the provider to get the details, and whether your residency in another county matters for your needs.

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  • Why would insurers not offer all their plans on the exchanges though? They're not the ones paying the subsidies. Like I said, they're still offering the plan in my county (or one that for all intents and purposes is identical), but not through the exchange.
    – Craig W
    Nov 6 at 22:37
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    @CraigW My bet would be technical differences. After that would be plans that are significantly different and don't qualify. It's not unusual for big companies to have two versions of the same product, the only difference being what market they sell it in. This is for their administrative benefit.
    – user26460
    Nov 6 at 22:42
  • It's also not unusual for big insurance companies to have a multitude of plans specialized for different customer bases. Big companies or unions may negotiate plans for their employees and/or their retirees, for example, and those may be big enough markets with predictable enough statistics that they can demand a few concessions from the insurers. Other organizations may or may not be able to do something similar, if they're large enough that the insurer sees them as a significant source of income.
    – keshlam
    Nov 7 at 2:46

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