Health Insurance

How health insurance works

A health plan shares the cost of your medical care with you. You pay a monthly premium to keep your coverage active. When you get care, you may first pay a deductible — the amount you pay before the plan starts sharing costs — and then copays or coinsurance for each visit or service.

Every plan also has an out-of-pocket maximum. Once your spending reaches it, the plan pays 100% of covered in-network care for the rest of the year. Many preventive services, such as yearly checkups and certain screenings, are covered without cost-sharing when you use in-network providers.

Comparing plans

Individual plans sold through the marketplace are grouped into metal levels — Bronze, Silver, Gold and Platinum. The levels describe how costs are split between you and the plan, not the quality of care. Bronze plans usually have lower premiums but higher costs when you need care, while Gold and Platinum plans cost more each month but less at the doctor’s office.

Networks matter as much as price. Before choosing, it is worth confirming:

• Your doctors and hospitals are in the plan’s network.
• Your prescriptions are on the plan’s drug list, and what they will cost.
• How the plan handles referrals and specialist visits.
• What you would pay in a realistic year of care — not just the monthly premium.

When you can enroll

In New Jersey, individuals and families can buy coverage through Get Covered New Jersey, the state’s official marketplace, during the yearly open enrollment period, which generally runs from November 1 through January 31. Outside that window, a major life event — such as losing job-based coverage, getting married, having or adopting a child, or moving — may open a special enrollment period for a limited time after the event.

New Jersey also requires most residents to have health coverage, or to pay a shared responsibility payment when they file their state income taxes, unless they qualify for an exemption.

How we help

We listen to how you use healthcare — the doctors you see, the medications you take and the care you expect in the year ahead — and then compare plans side by side in plain English. We will explain whether you may qualify for financial help, walk you through enrollment, and be there with answers when bills or questions come up during the year. If you are retiring before 65, we will help you bridge the gap and plan your move to Medicare.

Things to consider

• Look beyond the premium. A low monthly cost can mean higher bills when you need care.
• Report income changes. If you receive financial help, updating your income during the year helps you avoid surprises at tax time.
• Check the network every year. Doctors and drug lists can change when your plan renews.
• Turning 65 soon? Medicare has its own enrollment rules and deadlines — our Medicare 101 guide explains them step by step.