5 things you need to do when buying health insurance

5 things you need to do when buying health insurance
November 05 01:00 2015

5 things you need to do when buying health insurance

Steven Conner, a 56-year-old self-employed contractor in Gresham, learned recently his health plan premium will jump by $145 a month.

Conner is not alone. In June the state approved significant hikes for the more than 240,000 Oregonians who buy their own policies and are not on Medicare.

Even if you want to keep the same policy at a higher price next year, your plan’s provider network, drug co-pays and other fine print could change in ways that expose you to additional new costs.

That’s why you need to take stock of your situation and start shopping for a better deal now.

Open enrollment for people buying their own polices started Nov. 1. Consumers have until the end of December to get a new 2016 plan in place for January — or until Dec. 15 if they plan to get tax credits or other subsidies through the federal website, HealthCare.gov.

What the terms mean

Allowed amount: The maximum your policy will cover for any given service.

Deductible: What your policy requires you to pay before it covers a portion of your health care expenses.

Co-payment: A fixed amount you pay for a specific health care service covered by your policy.

Co-insurance: Your portion of the costs of a covered health care service, when it is not a flat copay.

Formulary: A list of prescription drugs that are covered by your policy, including how they are classified.

Out-of-pocket limit: The most a policy requires you to pay during the year, before your policy starts to pay 100 percent of the allowed amount. Some policies include exceptions to what is covered by the limit as well as what counts toward the limit.

Pre-authorization, prior authorization: A method insurers use to curb spending by requiring authorization by a primary care provider before covering a service.

Premium: Your monthly payment to your insurance carrier.

Provider network: The network of health care providers that your insurer contracts with to serve members of a particular plan. Network restrictions often are described using acronyms.

ν PPO, or preferred provider organization, typically is the least restrictive kind, with the consumer free to select a provider of their choice.

ν EPO, or exclusive provider organization, often indicates a more restrictive organization with the primary care provider serving as a gatekeeper for other

HMO, for health maintenance organization, indicates a closed network of providers working for the plan.
–Nick Budnick

The final deadline is Jan. 31 — far earlier than last year. If you miss it, you could be stuck without health insurance all year, exposing you to new, increased tax penalties the following April.

Here are some tips for assessing how your policy is changing and looking for alternatives on the market.

1. Take note of your health care now.

If you are trying to get a new 2016 plan in place by January, the deadlines will be upon you before you know it.

You need to prepare.

Shopping for the best plan means more than looking up the cheapest premium. Far more important is your total cost of health care under a given plan. What sort of safety net best fits your personality, family and needs?

Now is the time to sit down with a pen, paper or keyboard and brainstorm about your health care. Here are some questions you need to answer.

• How important is your doctor to you? How does the cost of staying with the same doctor compare with choosing an insurer that doesn’t contract with your doctor?

• Are you on prescription medications? How much is your co-pay? Will your plan cover your medication at the same rate next year?

• Are there surgeries or medical procedures you or your family plan to get in the coming year? Is there something you’ve been putting off?

• Would changing plans interrupt an ongoing treatment or hurt your ability to pay for it?

• If you have more than one person in your family, how do your needs differ?

You don’t need to perfectly answer every question. But sorting through your situation will help you as you jump into the market. You’ll be ready to talk to an agent and start shopping.

2. Check your income.

As many as 18,000 Oregonians left money on the table when they selected an insurance plan last year. That’s almost one in every 13 Oregonians who bought a private plan and were not on Medicare.

In some cases, these people lost out on big money.

People making 250 percent of the federal poverty level or less can enjoy lucrative increases in benefits or cost-sharing reductions as long as they select a “silver” level plan when they shop.

Since last year, federal law has required labeling plans bronze, silver, gold or platinum so consumers know the level of benefits they are buying.

Nearly 18,000 people bought a bronze plan, even though paying a little more might have saved significant cash over the course of the year.

This is just one reason why estimating how much you will likely make in the coming year is important to your preparation.

The cut-off for cost-sharing reduction is as much as $39,825 for a two-person household.

In addition to that benefit, there are tax credits available for those making up to four times the federal poverty level. These can be used in advance to buy down your monthly premium, or taken at the end of the year.

A family of four can make up to $97,000 and still qualify for the credits.

If you decide to tap the credits, you should buy your insurance through the federal website HealthCare.gov, or the state version of the portal, OregonHealthcare.gov.

3. Get an agent — a good one.

Consulting an insurance agent to help you assess your health plan options is a no-brainer. And they are swamped this time of year, so you need to call one now.

The advice costs you nothing. Insurers pay agents per member they enroll. Your premium won’t go up if you use one.

A good agent can help you negotiate some of the hidden fine print in the policies out there, and may help you if problems come up later in the year.

But while many Oregon insurance agents offer health insurance advice, their experience and knowledge varies.

Some specialize in only a couple of insurers, some don’t know how to use the health insurance exchange, while others don’t know much about health insurance, period. It may take multiple calls or meetings to find one you like. It’s worth looking at websites and seeing what agents are focused on health insurance and which are not.

When you do talk to an agent, consider it their audition, and ask questions:

How big a portion of their business is health insurance? If their true love is property/casualty, you might want to find a different agent.
How many health insurers do they contract with? Are they independent? There are seven insurers statewide, and nine in greater Portand. Some have 2016 rates that are not competitive. A truly independent agent will work with at least four competitive insurers, such as Providence, Moda, Oregon’s Health CO-OP and Regence.
Are they trained and certified? Using an agent certified for HealthCare.gov is crucial if your household income is low enough to qualify for tax credits and other subsidies. But other certifications and professional associations are good, too. They show a level of dedication as well as a support network for information and resources.

Are they familiar with the state’s consumer cost-sharing tool? This year for the first time, the state has released a spreadsheet (1.usa.gov/1MCOwgW) with cost-sharing details for every 2016 health insurance policy sold in Oregon, both on and off the exchange. Any consumer can use it to find the plan best suited to their needs, but having an agent to guide you won’t hurt.

As they answer your questions, listen to how your agent talks to you, not just what they say.

“Make sure you’re connecting with them. Make sure that they are listening to your situation. Are they doing the research, looking up your doctors and medications?” says Lisa Lettenmaier, a broker and co-owner of Health Source NW in Tigard. “There should be a dialogue.”…

Read full story at OregonLive.com
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