Millions of Americans, some with government financial assistance, purchased new Affordable Care Act health insurance plans last year. Then they encountered frustrating changes in doctor networks, formularies, and other aspects of their coverage. But it was a transitional year and things have settled down in some states. Now, those who want to change their Affordable Care Act (ACA) plans (whether purchased through a health insurance company directly or on the new insurance marketplaces) can take advantage of enrollment time, which starts Saturday. Nov. 15 kicks off annual enrollment and the ability to change health insurance plans for 2015.
For those considering making a plan change, doing so by Dec. 15 generally ensures the new premium and coverage will be effective Jan. 1, 2015. But note, the enrollment period does continue until Feb. 15 for those in ACA plans.
The plans are divided by metal levels with Platinum the most expensive and richest coverage, followed by Gold, Silver and Bronze (the least expensive). Depending on an individual’s situation, however, the cheaper plans may wind up costing more. Choosing a health plan involves weigh seven important factors:
Deductible: Insurance is supposed to be there in case something major happens. In many policies, there is a large deductible that must be satisfied before most coverage kicks in. (A deductible is an amount of money that the insured must pay up front before the coverage kicks in and starts paying for medical expenses.) Conversely, there are plans with little or no deductible. Sometimes the cost difference between the two is significant; other times changing the deductible has little impact on cost. Either way, preventive care visits and tests, such as a pap smear or well baby exam, are not subject to a deductible (and do not have copayments either).
Copayments/Doctor Visits – In many plans, there are small dollar amounts charged as copayments for doctor or specialist visits. They range from $20 for the more expensive plans to $60 or more for the less expensive options. Some plans with high deductibles may allow a limited number of doctor visits with a copay ($60 for example) before the deductible has to be satisfied. They do they so people do not hesitate to see a doctor if sick and wait until the condition is very serious. Copayments for specialist visits are often slightly higher than for primary care doctors. Also, check on the copay for urgent care and emergency room visits. These can really differ in how much the insured is expected to pay per visit.
Coinsurance – Coinsurance is a percentage of the amount an insured is expected to pay versus the insurance company. For example, if the coinsurance is 30 percent on a $1,000 procedure, the insurance pays $300 and the insurance company pays $700.
Out-of-Pocket Maximum – Twenty or 40 percent coinsurance does not sound that unaffordable on a $200 medical bill, but what about a sudden major medical emergency with a stay in intensive care? Costs skyrocket in these situations, but all health plans now have annual maximum out-of-pocket cost amounts. Above that threshold, the insure company pays 100 percent of the costs for the remainder of the year.
Prescription Drug Coverage – Some medical plans offer no prescription drug coverage until a deductible is satisfied or only cover generic drugs. Many have different levels of copayments based on whether the medication is generic, a common brand name drug and a more specialized high-end drug.
Premiums – Too many people make a decision based on the monthly premium. However, it is important to determine the total annual cost based on expected numbers of doctor visits at what cost, typical number of prescriptions, etc. A plan with a lower premium but higher costs if used can end up costing more than the more expensive plan premium-wise with lower costs when used.
Providers – The toughest shock for many people who bought we health insurance plans in the past year was determining which doctors and hospitals accept the coverage. For large carriers, such as Anthem Blue Cross of California, new networks were created adding to confusion so people who had Blue Cross one year and could see a particular doctor had Blue Cross the next year, albeit a different plan, but had to change doctors. If particular doctors or a hospital are important, a buyer needs to make sure they will accept the new health plan.
Take advantage, as enrollment time starts, to look at health insurance plans and determine what options provide the care and are most affordable. In addition, for those who qualify, apply for a subsidy/tax credits to help make that plan more affordable or have last year’s subsidy re-set to reflect current income and health insurance costs.
By Dyanne Weiss