Pumpkin time is also premium-shock time for many as open enrollment for health plans begins at most employers, large and small, and for people who purchased policies on their own or via the Affordable Care Act (ACA) marketplace. Companies set their own enrollment dates; ACA plan and individual enrollment begins Nov. 1; and Medicare enrollment began Oct. 15. When making a decision, there are several key things to watch for in the open enrollment information and in examining other health care options.
The amount due each month is a major deciding point for most, but should not be the only consideration. Sometimes there is a small amount of difference between a plan that only provides preventive care before satisfying a high deductible and one that allows some doctor visits or generic prescriptions with the deductible waived. Likewise, the most expensive plan is not going to provide better care if no doctor in the area accepts it.
The numbers of plan doctors offices have to contract with these days has grown considerably. It is not enough to ask if the doctor accepts Blue Cross’s HMO. There are many different HMO networks; differences in contracts for small business, large business, individual and Medicare plans. Health insurance companies have provider-listing apps on their Web sites and healthcare.gov is implementing one too. But, be sure to choose the right plan or the wrong answer might pop up.
Additionally, look at whether out-of-network coverage is available and at what level. Most HMOs only provide emergency coverage outside their area. But, many PPO plans implemented “EPOs” – which some called “extra small provider organizations” – that did not provide coverage outside the area. Other plans required people to get care within their state., which was problematical for people who lived near a border or regularly spent winters in Florida. After much criticism, many of these restrictions have been relaxed, but availability of providers where someone really expects to need them or particular providers should be a major part of their decision criteria.
The copayment for seeing a primary care doctor or a generic prescription get attention when people review plan options, but there are other ones to be comfortable with before committing. These include urgent care costs (some plans offer discounted urgent care copays at some pharmacy clinics), emergency rooms (this fees are high to discourage usage unless it is an emergency!), and the cost for name brand prescription regularly needed.
One of the other things to be aware of or watch for in open enrollment is that the penalties have increased for those who decline health care coverage. A major selling point of the Affordable Care Act was the requirement that every adult have insurance or pay a penalty (employers were also supposed to provide affordable coverage to ensure that happened). However, millions did not buy coverage and were undaunted by the small tax penalties imposed on them. However, the penalties increase for 2016 to the higher or 2.5 percent of the yearly household income or $695 per adult/$347.50 per child in the household. This makes the penalty comparable to the cost of the cheapest plan in some areas.
Written and directed by Dyanne Weiss
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