October 29, 2018
By Beth Battaglino, RN-C, CEO, HealthyWomen and
Michael Miller, MD, Senior Policy Advisor, HealthyWomen
Worried about health insurance? Most of us will have an opportunity to review our current health plans or choose new ones now through mid-December. Called "open enrollment," the time frame varies by the type of insurance and possibly by the state you live in.
The open enrollment period is the only time to make changes to your plan, except under certain circumstances. Take time now to review your options.
Here are important considerations when reviewing your health insurance options to ensure the plan you choose (or stay with) provides you with the best possible health coverage:
Insurance Terms to Know
- Premiums: What you pay per month for the insurance.
- Deductible: The amount you pay for care before insurance starts paying a portion of the medical care you receive. Some plans have separate deductibles for prescription drugs. However, some benefits (like preventive services) are covered without having to reach the deductible amount.
- Co-payment: A fixed amount you pay for a service (usually after meeting the deductible), such as $30 for a doctor's office visit.
- Coinsurance: A percentage of the amount charged for a medical service or product, such as 25 percent for a specialist office visit or a prescription drug. Because coinsurance is a percentage, you likely won't know how much a service or product will cost before you enroll.
- In Network: Some insurance plans have different co-payment and coinsurance amounts for doctors, hospitals, clinical labs, and other providers depending on whether they are "in network" or "out of network." And some plans do not pay anything for out-of-network care, except in some emergency situations.
- Formulary: A list of medicines that the health plan will pay for. These are arranged in "tiers" with different co-payment or coinsurance for each tier. Some medicines also require approval from the plan before they will pay for them—this is called "prior authorization." And some medicines may not be covered at all, which is like being out of network for medication coverage.
- Essential Health Benefits: Ten categories of care that many health insurance plans are required by law cover under the Affordable Care Act (ACA). (More about the ACA below.)
If a chronic medical condition is a concern for your family and you use a specific health care provider and/or specific medicines, determine if these needs are in network or out of network for the insurance plans you are considering. Also review the co-payment/coinsurance requirements, if you want to keep your current provider/medications.
Understanding Your Insurance Choices
Insurance through an employer:
If you are insured through your job (or through a spouse's or partner's job), information about your choices should come from that company—and most companies pay a portion of the monthly premiums. Many companies—particularly larger companies—offer options and let employees change plans during the yearly open enrollment period, typically several weeks ending in mid-December.
Buying insurance independently:
If you buy insurance on your own, you may encounter complications this year. While the insurance marketplaces created under the ACA have stabilized in some states, new non-ACA compliant options are appearing. Known as short-term/limited duration plans and association health plans, these options have significant pros and cons. For example, they likely will have lower premiums. However, they are not required to include all the categories of ACA-mandated essential health benefits, such as maternity care, preventive services, prescription drug coverage, mental health benefits, and other types of health care services you may need or consider to be important.
While these new options may present an attractive price point, you should carefully review them. Ask if they cover benefits that you or your family may need in the coming year. In addition, these short-term plans can limit how much health care they will pay for annually. You could face extremely high costs if you or your family were to develop a serious health issue.
For assistance in selecting individual or family insurance (also known as non-group insurance), check out www.healthcare.gov to see what options are available in your state. (Plan options are based upon what county you live in, so your options will be determined by your zip code.) Insurance brokers or local community organizations that provide insurance navigators may be available to help you choose and apply for non-group health insurance. (Visit https://localhelp.healthcare.gov to find local support.)
Depending on your income, you may be eligible for reduced premiums or help with co-payments and deductibles. You also may be eligible for your state's Medicaid program, which may have no monthly premiums. To determine your options, visit www.healthcare.gov (or your state insurance marketplace), or talk with a navigator or insurance broker who can help you determine which financial benefits you may be eligible for.
For more information about selecting health insurance wisely, visit:
- Aimed Alliance: Understanding Your Health Plan and Your Cost-Sharing Responsibilities
- Patient Advocate Foundation: Finding & Selecting Insurance
- Patient Advocate Foundation: A User's Guide to the Health Insurance Marketplace
- Consumer Reports: Guide to Health Insurance
- Health Insurance Resource Guide (Georgetown University)
Buyer Beware: Healthy Insurance that Seems Too Good to Be True Usually Is
With the proliferation of new insurance options (particularly Short-Term and Association Health plans), scammers are busy trying to "sell" bogus insurance—often through unsolicited phone calls. If you get a phone call offering you insurance that has a low premium, low deductible, great benefits and is called something like a "national plan," "now available because of new law" or similar, be wary. Take these steps:
- Do not agree to anything by phone.
- Ignore sale pitches describing plans with a "limited time offer."
- Do not share ANY personal information.
- Ask for a phone number so you can follow up. (Legitimate businesses want you to call them; scammers do not.) A nonworking number is another warning that the caller was trying to steal your information or your money.
For people with Medicare, open enrollment means you can choose a new Medicare Part D plan for prescription drug coverage and possibly switch from traditional Medicare to a Medicare managed care plan (Medicare Advantage)—or switch from one Medicare Advantage plan to another. Open enrollment for Medicare is October 15 to December 7. More information about Medicare open enrollment can be found here.
Know Your Options
For most people, choosing new insurance or switching plans is possible only during the open enrollment period. Therefore, it is important to do research to decide if you should stay with your current insurance or choose a new plan.
It is also important to understand how your current insurance may be changing for 2019 and how those changes may affect you. Don't assume nothing will change from one year to the next. Learn about four mistakes to avoid when selecting health insurance from Consumer Reports.
Learn what women nationwide think about their insurance options and other health care issues in HealthyWomen's recent WomenTalk 2018 survey.
We hope this short guide helps you choose the best insurance for you and your family, and supports your goals for being a HealthiHer and part of a healthy community for 2019.