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Buying Health Coverage on Georgia Access

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    Buying Health Coverage on Georgia Access

    What You Pay

    Here we are going to look at the types of expenses you have to pay if you get an individual plan for yourself or your family through Georgia Access. Then, we’ll look at what factors can make those expenses higher or lower.

    Expenses

    When you have an individual plan, you will need to pay a monthly premium, plus additional fees each time you get a service.

    The Monthly Premium

    The monthly premium is a set amount of money you have to pay each month to be part of a plan, whether or not you use any health care that month.

    Example

    Stephen is single and pays about $400 per month for his individual coverage plan.

    Additional Fees When You Get Care

    Each time you get care, you may need to pay additional fees. Which fees you have to pay and how much they cost will depend on your plan. Some plans only have copayments, while others have copayments, coinsurance, and deductibles.

    Copayments are a set amount you have to pay for a medical visit or service. The exact amount of the copayment varies depending on the service you get: medications, visits to specialists, lab tests, X-rays, emergency room visits, and other services can all have different copayment amounts.

    Example

    Under Stephen’s plan, he has to pay $40 each time he visits a specialist, $20 for each prescription drug, and $30 for each lab test.

    Coinsurance is a set percentage of the cost of a visit or service that you must pay.

    Example

    Under Stephen’s plan, he has to pay 20% of the cost of any surgery. So, if he has surgery that costs $5,000, he has to pay $1,000 and his insurance covers the rest.

    A deductible is a set amount of money that you pay out of your own pocket each year before the insurance company will begin to pay for certain services, including hospital care, emergency room visits, and, in some cases, prescription drugs. Once you have paid the deductible, you do not have to pay it again until the next calendar year.

    Family plans often have both an individual deductible for each member and a deductible for the entire family. Once the family reaches the family deductible, insurance will kick in for everyone on the plan, even if certain members haven't hit their individual deductibles yet.

    If you are under 30, you can sign up for a catastrophic plan with a high deductible. You will have to pay the deductible before this type of plan will pay for most Essential Health Benefits, though you will be able to see your primary care provider up to three times and get preventive care without paying the deductible.

    Tip: If you have to pay a deductible before your health plan will pay for your medications, ask your health care provider to prescribe generic medications, which are often much cheaper, then compare prices at different pharmacies to get the best price. You can also look on GoodRx for discounts and manufacturer coupons for generic or brand-name drugs.

    Example

    Under Stephen’s plan, there is a $2,000 annual deductible. If he needs to stay in the hospital for a few days, he will pay the first $2,000 of his stay. After he has paid that amount, he also has to pay 20% of the rest of the cost. If he goes back to the hospital later in the year, he will not have to pay the deductible again.

    Maximum Out-of-Pocket Expenses

    Each plan has a maximum amount you have to pay each year in fees for medical services (copayments, coinsurance, and deductible). This cap for your out-of-pocket expenses does not include the money you spend on your monthly premiums. The exact amount of your out-of-pocket maximum will depend on your plan and can range from $2,000 up to $9,200 for an individual or $18,400 for a family.

    Example

    Stephen gets a plan through Georgia Access that:

    • Has a $400 per month premium
    • Requires $40 copayments for visits to the doctor and $20 copayments for generic medications
    • Requires 20% coinsurance for hospital care and outpatient surgery
    • Has a $2,000 deductible
    • Has a $5,000 out-of-pocket maximum

    At the beginning of the year, Stephen is in a car accident and needs to go to the emergency room, which costs $2,000. He hasn't paid any of his deductible yet this year, so he pays the $2,000 out of pocket and meets his deductible.

    Then, he ends up needing major surgery that costs $15,000. He’s already paid his annual deductible, so now he just has to pay his 20% coinsurance, which means he pays $3,000 for the operation and his insurance plan covers the rest. Between the $2,000 he paid for the emergency visit and the $3,000 he paid for the operation, he has spent his entire out-of-pocket maximum for the year.

    Stephen has to stay in the hospital for three days as he recovers from his operation, and he also needs several medications to help the recovery and prevent infection. Usually he would have to pay 20% coinsurance for the hospital stay and a $20 copayment for each medication, but because he already spent his out-of-pocket maximum this year, he doesn’t have to pay anything—his insurance plan will cover it all. In fact, other than continuing to pay his $400 monthly premium, Stephen will not have to pay anything for any of his health care for the rest of the year.

    What Affects How Much You Pay

    The amount you pay for these expenses if you get an individual plan through Georgia Access depends on these main factors:

    • The level of health plan you choose
    • The type of plan you get
    • Your family’s income
    • Where you live
    • Your age, and
    • Whether you use tobacco.

    Note: Health plans used to charge people more based on their gender or whether they had pre-existing conditions. That is no longer allowed. People can only be charged more based on the factors listed here.

    Health Plan Metal Levels

    There are four different levels of plan available to most people:

    1. Platinum plans have the highest monthly premiums and the lowest fees when you get medical care.
    2. Gold plans have slightly lower premiums and slightly higher fees when you get medical care.
    3. Silver plans have lower premiums. The fees for medical services depend on your family’s income; if you make less than 250% of the Federal Poverty Guidelines (FPG), the fees may be as low as a gold or platinum plan.
    4. Bronze plans have the lowest monthly premiums and the highest fees when you get medical care.

    Health Plan Types

    There are two main types of private health plan available through Georgia Access:

    • Health Maintenance Organizations (HMOs) have a specific network of health care providers, including doctors, hospitals, labs, and pharmacies. You choose a primary care provider (PCP) from their network. When you have a medical problem that isn’t an emergency, you may need to see your PCP first. If your PCP thinks you need to see a specialist, your PCP will write you a referral to see another doctor in the network. You can only get services outside your network in an emergency.
      • The Bottom Line: HMOs have lower costs than PPOs, but you have fewer choices of health care providers.
    • Preferred Provider Organizations (PPOs) also have a network of doctors, but you can usually see any doctor in the network, including specialists, without a referral from a primary care provider (PCP). You can also see a doctor outside of the PPO network, but you will have to pay a higher portion of the bill.
      • The Bottom Line: PPOs offer more physician choice, but they usually have a deductible and your premium and total out-of-pocket costs may be higher than in an HMO.
    Plans with Health Savings Accounts (HSAs) Help Families with Higher Income Most

    Some health plans on Georgia Access let you create Health Savings Accounts (HSAs) to set money aside to help you pay for certain approved medical expenses. For example, you could use the money in this account to pay for expenses like doctor’s visits or prescriptions that aren’t paid for by your insurance before you meet your deductible.

    You decide how much money to put into the account, up to a certain limit. The big advantage of these is that you don't have to pay taxes on the money you put into the account. The higher your tax rate, the more HSAs can help you save money—if you have a low tax rate, they probably won't help you very much. HSA-eligible plans have the trade-off that they have high deductibles, so they could actually make health care more expensive for some people.

    Learn more about HSAs.

    Your Family’s Income

    Families that make less money and don’t have employers who provide affordable coverage may get government help paying for their health care:

    • The government may help pay for your premium through tax credits. That means you would pay less each month. You might get this help no matter what metal your plan is. Note: There is no maximum income limit for getting subsidies that help pay individual coverage premiums. (Before 2021, the limit was 400% of FPG.) To get subsidies, you still must meet other eligibility rules and the premium amount you pay depends on your income and your plan.
    • If you make 250% of the Federal Poverty Guidelines (FPG) or less and get a silver plan, you'll also have reduced costs, including lower copayments and co-insurance and a lower deductible and out-of-pocket maximum. That means you pay less each time you need medical services. A silver plan with these lower costs might actually be as good or better than many platinum or gold plans. You only get these cost reductions if you get a silver plan.
    Health Coverage Income Limits for Your Family
    How the government helps pay for your coverage via tax credits

    Depending on your situation, you may qualify to have the government help pay for your individual health plan via tax credits. Here's how it works:

    1. When you sign up at Georgia Access, you give details about your family's situation. Georgia Access reviews that information instantly. If your family qualifies for government help to pay for individual coverage, Georgia Access tells you and lists insurance options for you.
    2. Your insurance options list the full cost of the monthly premium, how much of that premium the government will pay each month, and how much you will pay each month. The way the government helps pay the premium is by giving you a tax credit every month, so you don't have to think about it during the year. All you have to do is make sure you keep paying your part of the premium.
    3. In January or February, the government will send you a form listing how much your total health care tax credits were for the previous year. You will need this form at tax time, because it is possible the government paid more or less than it should have for your health coverage. If so, this will be sorted out when you file your taxes.

    Where You Live

    Different providers offer different plans in different parts of the state and the prices of these plans vary.

    Your Age

    The older you are, the higher your monthly premium. However, older people can only be charged a premium that is at most three times what a young person would be charged.

    Whether You Use Tobacco

    If you use tobacco, you will pay a premium that is up to 50% more than what non-tobacco users pay.

    Things to Think About

    When you use Georgia Access to get health coverage, you can control two of the things that affect how much you pay for your coverage: you choose the level of plan you want (platinum, gold, silver, or bronze) and what type of plan you want (HMO or PPO).

    Here are some questions to think about as you compare plans:

    • Do you qualify for government help paying for your health coverage?
    • How high a premium can you afford to pay each month?
    • How often do you visit the doctor or need other medical services? For each plan, add up the copayments you would need to pay for your usual appointments, then combine that cost with the monthly premium to see the total monthly cost of each plan.
    • Do you like your current doctors? Which types of health coverage do they accept? Are you willing to switch doctors to save money?
    • Are you okay with having a primary care physician who refers you to specialists when you need them? Or do you prefer being able to set up appointments with specialists on your own?
    • Are you comfortable with having a deductible for hospital care, outpatient surgery, and emergency room services?

    Each family has a different situation, and the right answers for you will depend on your specific needs. For example, if you know you will have to go to the doctor a lot, you may want to make sure that you don’t have high copayments. Or, if you hardly ever go to the doctor, you may prefer to have a lower premium.

    Check out Shop and Enroll on Georgia Access to browse plans and see how much you might have to pay each month for a silver level plan.

    Example

    Sonia and Anthony have two little children. Sonia makes $66,000 per year (a little more than 200% of the Federal Poverty Guidelines for a family of four) at her job, but her employer doesn’t offer health coverage for its employees, so her family has to pay for an individual plan. Anthony is a stay-at-home dad.

    Sonia is a little nervous since her family doesn’t make a lot of money, but she knows that there is supposed to be an affordable option for every family, so she decides to check out Georgia Access. Georgia Access asks her for some basic info, including where they live, how much income the family has, the age of each family member, and whether any of them uses tobacco (none of them does).

    Once she’s answered these questions, Georgia Access shows Sonia that her two children are eligible for PeachCare for Kids and that she and her husband qualify for a government-subsized silver-level plan. She chooses a plan for the two of them that has a premium they can afford, low copayments, and no deductible.

    If you can no longer afford your plan

    Usually, when you sign up for a plan through Georgia Access, you cannot change plans for an entire calendar year. So, if you are signed up for 2025, then you can’t get a new plan until 2026.

    However, there are certain situations when you may be able to change plans mid-year:

    • If your income changes and you gain or lose eligibility for government help paying for your coverage
    • If you move
    • In other life-changing circumstances, such as having a child or getting married

    The first one is the key. If your income goes down and you can’t afford your plan anymore, you need to report your change in income to Georgia Access. You may qualify to get Medicaid or to have the government increase how much it pays for your current insurance via tax credits (meaning that you have to pay less).

    Different Requirements for American Indians

    If you are a member of an American Indian tribe recognized by the federal government and you earn less than 300% of the Federal Poverty Guidelines ($45,180 per year for an individual, $93,600 for a family of four), you will not pay any copayments or deductible for the health insurance plan you get through Georgia Access.

    American Indians can also change health plans up to once a month.

    Learn more

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