Choosing and using health insurance can be confusing. Whether you are insured or in the health insurance market, it can be difficult for you to understand the terms of your plan or the ones you are considering.
You are not alone. The details of health insurance plans can seem overwhelming, but it is important to understand them, especially before choosing one. This way, in the event of a sudden illness or emergency, you will not try to carry over your coverage details to a time that is difficult enough.
Sources of information on health insurance
According to a 2020 U.S. Census Bureau report, 92% of Americans had health insurance in 2019. More than half receive insurance from their employer. About one-third of the US population has Medicaid or Medicare coverage .
About 6% have coverage purchased on the marketplace (exchange) or an over-the- counter plan ( basic health insurance is purchased directly from an insurance company that complies with the Affordable Care Act).
Regardless of how you get coverage, there are resources to help you choose the best plan for you and your family, complete the enrollment process, and use health insurance when you need it.
If you have health insurance for work , contact your company's human resources department. Feel free to ask as many questions as necessary; this department is there to help you understand the health plan options that are part of your benefits.
If you work for a small business that does not have a human resources department , you have several sources of information to turn to:
- Insurance company
- The broker who helped your employer select coverage (ask your manager for guidance)
- Your State 's Small Business Health Insurance Marketplace
- Your employer's third-party payroll / benefits company, if applicable
If you buy insurance yourself (for example, because you are self-employed), brokers can help you online, over the phone, or in person for free. They can help you compare plans both on and off the exchange .
If you know you want to become a member of the health insurance market , certified navigators and consultants can help.
For Medicaid or the Children's Health Insurance Program (CHIP), your state agency can help you understand if and what you or your family are eligible for, and can help you register. In many cases, you can also enroll in Medicaid or CHIP through your state's health insurance exchange.
If you are eligible for Medicare , you can use your State Health Insurance Assistance Program as a resource. There are also brokers nationwide that help beneficiaries enroll in Medicare Advantage plans , Part D prescription drug plans, and Medigap supplemental coverage for Original Medicare.
Weighing your options
In some cases, the insurance plan options are limited (for example, if the employer only offers one option). But most people have several options.
Your employer may offer a variety of plans with different levels of coverage and monthly premiums. If you buy your own health insurance, you can choose any plan available in a separate market in your area (on the exchange or off the exchange, although premium subsidies are only available on the exchange, keep in mind that premium subsidies for 2021 and 2022 they are more than acceptable, due to the American bailout plan , which was adopted in March 2021. ).
If you are eligible for Medicare, you will have the option to choose a Medicare Advantage plan or stick with your original Medicare plan and supplement it with Medigap and Part D prescription drug coverage (Medicare Advantage plans are not available in some counties. ).
For all types of coverage except Medicaid / CHIP, annual open enrollment periods apply. However, there are special enrollment periods available if you have experienced certain qualifying life events, such as involuntary loss of insurance or marriage.
When it comes to health insurance, there is no one-size-fits-all solution. The right plan for you depends on many factors:
Do you have a pre-existing condition?
(Note that the ACA reforms do not apply to Medigap plans , which may still have health coverage under certain conditions. They also do not apply to plans such as short-term health insurance and fixed reimbursement policies, which also follow using health insurance. Insurance.)
However, if you have a pre-existing medical condition, you will want to consider what you need from your insurance to deal with it, as benefits, out-of-pocket costs, covered prescription drugs, and provider networks are very different from one. . plan another.
A plan or two?
If a member of your family already has a medical condition or expects significant medical costs over the next year, consider adding the family to separate plans with better coverage for the person who needs more medical care during the year.
Are you taking any prescription medications?
Be sure to check the formulary (drug lists) for your planned health plans. Health plans divide covered drugs into tiers, commonly known as Tier 1, Tier 2, Tier 3, and Tier 4 (sometimes there is also Tier 5). You may find that one plan covers your drugs at a lower level than another, or that some plans don't cover your drugs at all.
Tier 1 drugs are the least expensive and Tier 4 or 5 drugs are mostly specialty. Tier 4 and Tier 5 drugs are generally covered for a copayment (you pay a percentage of the cost) rather than a fixed copayment.
Given the high cost of specialty drugs, some people end up paying the maximum out-of-pocket in their plan at the beginning of the year if they need expensive Tier 4 or 5 drugs. However, some states have restrictions on patient spending on drugs. specialty.
If you are enrolled or already covered by Medicare, you can use the Medicare Plan Finder when you first enroll and every year during open enrollment. This will allow you to enter your prescriptions and help you determine which recipe plan is best for you.
Do you want help from a specific provider?
Provider networks vary from operator to operator, so compare the provider lists for the different plans you are considering. If your service provider is not in the network, you can still use that provider, but at a higher cash rate , or you may not have any out-of-network coverage.
In some cases, you will need to decide whether to continue paying higher health insurance premiums while staying with your current healthcare provider. Unless you have a particularly strong relationship with a particular healthcare provider, you may find that choosing a plan with a limited network can lead to lower premiums.
Are you expecting expensive medical care in the near future?
If you know that you or a covered family member is about to have surgery, for example, or if you plan to have a baby, it might make sense to pay higher premiums in exchange for a plan with a lower cash limit. …
You can get better value from a plan with a lower total cash limit, regardless of how much the plan has to pay for individual services before this threshold is reached.
For example, if you know that you will need a knee replacement, a plan with a $ 3,000 total cash limit may be more beneficial than a plan with a $ 5,000 cash limit. Although the last plan offers copays for visiting a doctor, the first plan takes into account visits to your franchise's PCP.
Ultimately, you would be better off paying the full cost of your doctor visits if you knew that all of your medical costs for covered services would end once you earn $ 3,000 a year.
Getting a copayment for a doctor's appointment, rather than full cost, is beneficial in the short term. But for people who require extensive medical care, the overall out-of-pocket limit may be a bigger factor.
You travel a lot?
You can choose a Preferred Provider Organization (PPO) with a large network and reliable out-of-chain coverage. It will be more expensive than a narrow network healthcare organization (HMO), but the flexibility it offers in terms of being able to use providers in multiple areas can be worth it.
PPOs are generally widely available to people who get coverage from an employer, but they are much less common in the individual / family market (where people buy coverage if they don't have access to an employer's plan).
There are no PPO or POS plans available in many regions of the country, which means that members will not be able to choose a plan with out-of-network coverage.
If you have Medicare and travel a lot, Original Medicare (plus additional coverage) is likely a better option than Medicare Advantage, since Medicare Advantage has limited provider networks that tend to be localized.
How comfortable are you with risk?
Would you rather spend more on premiums each month in exchange for lower out-of-pocket expenses? Is it worth a copayment at a healthcare provider's office, instead of paying for all services until you collect the deductible, the higher premiums? Do you have any savings that can be used to pay for medical expenses if you choose a plan with a higher deductible?
These are questions that don't have a right or wrong answer, but understanding how you feel about them is a key part of choosing the health plan that will give you the best value. You will have to pay your monthly premiums regardless of whether you use million dollar health care services or not.
But in addition to premiums, the amount you pay during the year depends on the type of coverage you have and the medical care you need. All non- grandparent plans cover some of the preventive maintenance services with no cost sharing, which means there is no copayment and you do not have to pay your deductible for these services.
But beyond that, coverage for other services can vary significantly from plan to plan. If you choose a plan with the lowest premiums, keep in mind that your costs will likely be higher if you need medical care.
Want a Health Savings Account (HSA)?
In this case, you must make sure you participate in a High Deductible Health Plan (HDHP) that is HSA compliant. HDHPs are regulated by the IRS and it is important to understand that this term does not just refer to any high deductible plan.
These plans cover preventive maintenance up to the deductible, but nothing more. HSA-eligible plans have minimum deduction requirements along with maximum out-of-pocket limits.
You and / or your employer can fund your HSA and there is no use or loss clause. You can use the money to pay for medical expenses in pre-tax dollars, but you can also keep your money in the HSA and let it grow.
It will roll over from one year to the next and can always be used, tax-free, to pay for qualified medical expenses, even if you no longer have an HSA-qualified health plan (you need current HDHP coverage to contribute to the HSA, but do not withdraw funds ).
Get the word of drug information
Health insurance is necessary, but it can also be frustrating and difficult. Whether you have a government plan, coverage offered by your employer, or a policy that you bought yourself, a solid understanding of how health insurance works will go a long way.
The more you know, the easier it is for you to compare plan options and know that you are getting the most out of your health insurance. And rest assured, help is always available if you have questions.