by Dr. (Mrs.) Omobukola Olaoye | There are three things to look for when renewing your health insurance; who is in the network as determined by the managed health plan type, what is covered, and what are the metal tiers within the managed plans?
As of today, November 1st, you can join or change your health insurance plan for next year. As you may know, the plan changes from year to year. Which is why it’s wise to compare your health insurance choices from different companies before you choose one before the deadline of December 15th. The changes you make to your health Insurance plan will not take effect until January 1st next year.
The health insurance terrane is now all about patient choice, (Fotaki, 2013, Marquand, 2018). Which means our choice of health insurance is contingent on our current situation. When it comes to the choice of the most suitable health insurance plan for me and my family or for you and your family, it is about weighing the cost and benefit in our current situation and choosing that which brings us the most value. People tend to choose acts with maximum expected utility, (Maziak and Ward, 2009; Briggs, 2017). That is, informed people tend to behave in their best interest, hence make rational choices.
Therefore, the goal of this article is to provide information that may assist you in choosing the most appropriate individual health insurance plan as we consider renewing our health insurance. Thank God for the growing ease of access to information through various means of communication and information technology, regardless of inequalities of education and income, hence more people can make informed decisions, in this case the choice of the health insurance that best fit our current situation, (Maziak and Ward, 2009).
Open enrollment is upon us, that means a time when one could make changes to one’s health insurance coverage. These changes include, but are not limited to switching plans, adding a coverage or removing unneeded coverage. Prior to 2014, one could purchase health insurance at any time during the year, however, now, one can only buy health insurance during open enrollment, unless one has a special circumstance such as becoming a U.S. citizen, gaining status as a member of an Indian tribe, moving outside one’s insurer’s coverage area, leaving incarceration, getting married or having a baby. Others include losing other health coverage due to divorce, COBRA expiration, job loss, change in income or household status, aging off a parent’s plan, or losing eligibility for Medicaid or the Children’s Health Insurance Program (CHIP), (Masterson, 2018; Marquand, 2018). One can get Medicaid or CHIP (federal and state insurance programs for low-income families) at any time of year though. Open enrollment typically starts around November and ends in December. However, some States like California, Colorado, D.C., Massachusetts, Minnesota, and New York have varied start and end dates. So, check your State’s begin and end date for enrollment, (Healthcare Markets).
What to look for?
There are three things to look for when renewing your health insurance; who is in the network as determined by the managed health plan type, what is covered, and what are the metal tiers within the managed plans? Some health insurance companies, on their websites, educate health insurance consumers on the differences between the different health plans. The consensus is that each insurance plan is different because they each pay a different set share of costs for the average enrolled person, (Masterson, 2018; Medical Mutual).
How much you pay per month/per year depend on the health plan structure and metal tier you choose. So, you need to review the plans diligently before making a choice that is within your budget, by comparing the annual premium, deductibles, co-payments and co-insurance between health plans with the same coverage.
Premium: There is a monthly payment you make to your health insurance company You pay this monthly bill regardless of if you use medical services or not. Then you pay the associated out-of-pocket costs when you receive care.
Deductible: This is one of the out-of-pocket costs you pay each year for coverage before the health plan pays on your behalf, except for preventive care.
Co-payment: Refers to the payment you make for each office visit. Some health plans do not have co-payments.
Co-insurance: After you have met the deductible, co-insurance is the percentage of covered health care charges you pay.
- The Network Structure
Managed health care provides its members with quality medical care and services by providing members access to a comprehensive health care system. Managed plans contract with clinics, doctors, home healthcare agencies, hospitals, laboratories, medical equipment vendors, pharmacies and x-ray centers to provide members with needed health care services, (Masterson, 2018). Access to providers in a network depend on the type of managed health insurance plan you choose. (Healthcare.gov). These different managed plans, according to their popularity, are health maintenance organization (HMO), preferred provider organization (PPO), point of service (POS) or Exclusive provider organizations (EPOs) (California Health Plans). Some managed plans types allow flexibility in your use of almost any doctor or health care facility. While other plans limit your choices or pay less of the cost if you use out-of-network providers, (Humana). Table 1 shows a comparison between health plans relating to PCP choice, network limitation (if there is any), what you pay, claims paperwork (if needed), and choice consideration.
HMO: HMOs have an entire network of health care providers who have agreed to offer its services. HMOs regularly focus on prevention and wellness by providing integrated care. Thus, covered services include preventive care, specialist visits referred by your PCP, and a host of other health and wellness benefits.
PPO: PPOs provide you with more flexibility than the HMO.
POS: Though not as popular as HMO and PPO, it is a hybrid of both the HMO and PPO plan. Under the POS, you get the combination of the PPO flexibility with the HMO low-cost plan.
EPO: This is also some type of hybrid of both HMO and PPO.
Catastrophic Plan: For those under 30 years. The 2018 deductible for an individual was $7,350 and $14,700 for a family, (Miller, 2016; Marquand, 2018; Norris, 2018).
High-Deductible Health Plan with or without a Health Savings Account: Like a catastrophic plan, you may pay less for health insurance with a high-deductible health plan (HDHP). With an HDHP, you may have one of the managed health plans such as HMO, PPO, POS or EPO, but with a higher out-of-pocket cost than any other plan. Like other plans, the HDHP pays 100 percent of your care cost once you reach the maximum out-of-pocket amount. The deductible under the HDHP for 2018 was as low as $1,350 for an individual or $2,700 for a family but was no more than $6,650 for an individual and $13,300 for a family. (Marquand, 2018; Norris, 2018). With your enrollment in a HDHP, you may have a health savings account (HSA) to assist in paying for your care. The money set aside in an HSA is not taxed and can only be tax-free if you use the money to pay for eligible medical expenses. In addition, unused money in your HSA rolls over to the next year. You also can keep the HSA even if you change health plans. More so, when you retire, you can use the money for non-medical expenses. Some bronze plans (a metal tier) may qualify as a HDHP depending on the deductible. (Marquand, 2018; Norris, 2018).
Table 1. Managed Health Plans Compared
|PCP||You must choose a PCP who coordinates all your health care and services.||You are better off choosing a PCP within the network, but you do not need a PCP to refer you to a specialist before seeing one.||You must elect an in-network physician as your PCP who will refer you to specialists.
|You do not need a PCP referral to a specialist before you choose to see one, if such specialists are within the provider network.
|You may see any in-network providers, however with full understanding of any additional rules relating to seeing specialists.||Depends on the managed health plan you choose. (HMO, POS, EPO, or PPO)
|Network Limitation||Limited to only the doctor and hospitals within the network. No out-of-network coverage, except in an emergency.||The plan will pay less for out-of-network cost on your behalf than if you received services from providers within the network.||You pay less if you see in-network health care providers in the POS plan.
|You have access to all in-network providers. Plan will not cover out-of-network services, unless it is an emergency room visit.||You may see any in-network providers. Ensure you fully understand any additional rules relating to seeing specialists.||The doctor you see under the HDHP varies depending on which managed health plan (HMO, POS, EPO, or PPO) you choose.
|What you pay||Typically comes with low or no deductibles, and the premiums are generally lower that other managed care health plans. There is no required deductible for preventive care. But non- preventive care requires copayment fee (typically a low fee) and may require an annual deductible. In addition, there may or may not be a copay each time you receive care, as well as a co-insurance.
|Premiums tend to be higher, and you will have a deductible, which may be higher for out-of-network services. There is a co-payment for doctor’s office visits and some other services, which may be smaller if you see an in-network provider. There may also be a co-insurance, which is typically higher out-of-network providers.
|In addition to your premium, you may have to meet your deductible before the plan pays for non-preventive care. The deductible could be higher for out-of-network services received. There is also either a copay or a co-insurance, which are higher for services received from out-of-network providers.
|You may pay a lower premium than a PPO offered by the same insurer. If there is a deductible, plan pays 100 percent of your care once you reach the maximum out-of-pocket amount. You will also have a copay or a co-insurance to pay. No coverage for out-of-network services.
|Plan offers a lower premium, and you get three primary care visits before your deductible applies. There is free preventive care, even if you haven’t met the deductible Like other plans, the catastrophic plan pays 100 percent of your care once you reach the maximum out-of-pocket amount.
|Plan comes with a lower premium compared to other plans. Like other plans, your preventive care is free even if you have not met the deductible. There is no co-insurance or copay under the HDHP because you must pay the full cost of all other non-preventive medical care up to your deductible. You may use you HSA money to meet these costs. The plan then pays 100 percent after your deductible is met.
|Claims Paperwork||No claims paperwork to complete because plan will not pay for out-of-network care.
|The PPO plan requires more paperwork than other plans because you may use out-of-network providers.
|You will need to complete a moderate amount of paperwork for seeking reimbursement for out-of-network services received.
|No claims paperwork to complete because plan will not pay for out-of-network care.
|No out-of-network coverage. However, you will need to track your medical expense to know when you have met your deductible for non-preventive care coverage.||Depends on the managed plan you choose|
|Consideration||If your PCP visits are only for routine check-up and for coordinate your other health services such as ordering tests and referral to specialists.
Also, if you want lower out-of-pocket costs.
|If you want the flexibility of access to more providers without the need for a required PCP referral.
If you already have a doctor or medical team that you want to keep.
|Maybe for small businesses with employees who work in several cities. The employees will have access to more provider options along with a PCP to coordinate their care for additional services such as lab tests and specialist care.
|If you want lower out-of-pocket costs as well as the no-PCP-referrals requirement to see a specialist.||If you are below the age of 30, and you are looking for a low premium plan.||If you want to save money by paying low monthly premiums and you do not plan to use your medical coverage extensively. In other words, these plans may be right for you if you are healthy and have some money in the bank.
- The Coverage
One cannot be denied health coverage or charged more because of previous sickness otherwise known as pre-existing condition, (Speights, 2015; Marquand, 2018; Masterson, 2018). That being said, and with the knowledge of the different managed plans to choose from, now there is a need to ensure that the plan you choose meets your need, appropriately, in your family’s current situation. The Affordable Care Act (ACA) mandates that plans should cover certain care, at the minimum, (Healthcare.gov). Under the ACA, plans must cover routine medical care (doctor’s office visits), lab tests, specialist care and prescription drugs. Emergency room visits, hospitalization (such as surgery), services and devices for recovery after an injury or due to a disability or chronic condition. Others include mental health and substance abuse treatment, pregnancy and maternity care, prescription drug coverage, as well as pediatric services, including dental and vision care for kids. Coverage must also include preventive services such as immunizations and birth control, and a variety of health screenings as needed.
However, based on your current situation, do you need more? For instance, will you benefit from having a plan that covers not only generic prescription drug coverage, but include brand name coverage? Or do you need a plan that covers not only post-surgery care at home, but also covers custodial care (personal care) at home? Custodial care is a type of long-term care (LTC) that meets the need for non-medical care by assisting individuals, who cannot help themselves, such as daily routing activities like eating and bathing. This care may be met in a nursing facility or at home, (Investopedia; CMS). If you do need custodial care, then you want to choose a plan that has such home care provisions in their policy. Generally, Medicare does not cover custodial care, (Medicare.gov). Medicaid covers custodial care, if you qualify, (LongTermCare.gov) otherwise you need to look into LTC insurance, (AARP).
In addition to overall medical care, a plan with dental and vision coverage is beneficial, although it will cost more. If what is offered can still not meet your needs, there is always supplemental insurance to bridge the need gap. Basically, you need an insurance that covers the care you need at an amount you can afford.
- The Category
Health plans are grouped by how you and your insurance split the cost of care by way of premium, deductible, and out-of-pocket costs (co-payment and co-insurance). These categories are also referred to as metal tiers. The percentages of how much you pay are estimated based on how much medical care an average person would use in a given year, (Healthcare.gov). This is where you decide if you want to choose a plan with lower premium but a higher out-of-pocket cost because that is all you can afford or vice versa. It is important you consider the likely frequency of your doctor’s visit.
There are four categories of health plans to choose from, they are Bronze, Silver, Gold and Platinum. Comparing health plans by their metal levels will assist in making a choice of the best plan for you.
- Bronze – You and your health plan have a 40-60 split.
- Silver – You and your health plan have a 30-70 split.
- Gold – You and your health plan have a 20-80 split.
- Platinum – Plan pays 90 percent of your health care costs. You pay 10 percent.
However, it is possible that plans in the same metal level split costs differently. For instance, two Silver plans may have different deductibles and co-insurance categories, ultimately, their overall out-of-pocket costs are expected to be the same. Likewise, plans in the same metal tier may be structured differently. One Silver plan might be an HMO while another might be a PPO. The plan type you choose will determine if you have free access to any provider in your network or if you need a referral from a PCP to see a specialist.
Generally, the less you pay out-of-pocket towards the deductible, and for the co-payments and co-insurance, the more you pay in premiums for the coverage, (Marquand, 2018; Masterson, 2018; Healthcare.gov). If you are not likely to go to your doctor frequently, you may be better off purchasing a high-deductible with a low premium health plan like a Bronze plan, (Masterson, 2018).
As you sift through all the insurance information for consideration in your current situation, it bores down to which health insurance plan you consider will add value to your family health. What treatment do you need? Is it available and is it affordable? Hence, some people choose to travel outside their country to seek heath treatment (Medical Tourism) because it is the most viable option for them. Do we need short-term, or temporary, health insurance plans outside the open enrollment period? Bear in mind though that these temporary plans provide only limited benefits. What about a managed plan that has a local doctor in a provider network, more flexibility and health coverage that comes with a higher premium, or do you want a plan with lower premiums that comes with a higher-out-of-pocket costs?
The choice is yours. You cannot be declined for an individual health plan, regardless of your health history, and insurance companies cannot charge you more because of your medical conditions. Likewise, health plans cannot cap the amount of your benefits, and they cannot make you pay more than a certain amount out of pocket each year for the health care you receive. Keep in mind, plan categories have nothing to do with quality of care, (Marquand, 2018). So good luck.
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