If you and your family need individual health insurance, your open enrollment period ends March 31. After that, purchase of an individual plan that satisfies the Affordable Care Act’s requirement for this year to be insured will be restricted to those who are affected by significant life events, such as marriage or the birth of a child. This applies whether you buy your plan from the federally run exchange, or from an individual broker.
Through the exchange, only two companies in the Kansas City area offer health care coverage, Blue Cross and Blue Shield of Kansas City, and Coventry. If you qualify for a government subsidy, to get it you must choose a plan from the exchange. If you do not qualify for a subsidy, your choices expand to include other companies such as United Health Care and Humana.
How do you select the plan that is best for you? To sort through the many variables within health insurance policies, it is wise to work with a navigator or insurance broker to evaluate plans that will best meet your needs.
The first consideration is to establish that your preferred physician and preferred hospital are in the plan’s network. Be aware that some companies offer more than one network, and premium costs are likely to vary by network.
The next step is to have a broker look at the consumer complaint index, published by the insurance department in your state of residence. Further, is your company of choice financially stable? Will it be there when you need it?
All insurance providers are rated by the National Committee for Quality Assurance, which evaluates each company on clinical outcomes, and provider and patient satisfaction standards.
Evaluation of the value of a plan may be the most misunderstood element of the process. Most consumers are aware that the premium is based on such factors as location, age and tobacco use. Often the decision process mistakenly stops there.
Further “cost-sharing” expenses can be considerable. They include deductibles, co-pays and co-insurance. A deductible is a dollar amount paid by the consumer before any costs are covered by his policy. A co-pay is a fixed amount paid for a covered health service, usually when the service is received. Co-insurance is a patient’s share of the costs of a covered health care service, calculated as a percentage. These percentages vary by the plan selected. These out-of-pocket costs can vary widely from plan to plan.
Does the plan meet the minimal requirements of care according to the new legislation? Thousands of Americans lost coverage January 1 because their policies did not meet minimum standards of care. The end to these policies dismayed many consumers and became a rallying cry for opponents of the Affordable Care Act, because President Barack Obama had said people who liked their insurance policies could keep them.
But many of those plans were of such low value as to be a waste of money. Here is a real life example of how a plan not meeting the minimum standards was not worth much in the end:
Lawrence Yurdin, a 64-year-old computer security specialist, had two heart procedures at St. David’s Medical Center in Austin. His policy covered up to $150,000 a year in hospital care. However, both the hospital and patient missed the fine print:
• Coverage for hospital care was mainly limited to “room and board.”
• His policy limited “other hospital services” to $10,000.
• “Other services” included charges for surgery, tests, medications.
• Total unpaid medical bills: $200,000.
As a result, Yurdin was forced to declare bankruptcy. Sham plans such as this have, for the most part, been discontinued, though the White House has allowed their extension in states where insurance regulators also approve.
The law’s new standards call for a comprehensive package of items and services known as “essential health benefits.” These benefits cover 10 categories of care: emergency services; hospitalization; laboratory tests; maternity and newborn care; mental health and substance abuse treatment; outpatient care; pediatric services (including dental and vision care); prescription drugs; preventive services (such as immunizations and mammograms) as well as management of chronic diseases (such as diabetes); and rehabilitation services. These are usually covered by employer-sponsored group plans. Before the Affordable Care Act, this coverage was often lacking in individual plans.
It is also necessary to learn all the plan’s requirements and procedures for getting care. Do you need to use only the doctors on the plan’s list? Are there special constraints, such as requiring a referral from your primary care physician for specialists, surgery, lab, or X-ray? What procedures are required for a referral? Is there coverage for out-of-network care? What benefits are not covered? What are the appeal procedures?
Choosing the health plan that is just right for your family is as complicated and fun as doing your own income taxes — and just as vital to get right. But the process is often simplified by working with an expert such as a navigator, agent or broker, to be sure that your needs are met in the best way possible.