What to Know When Shopping for Health Insurance

Below are some of the most commons concerns when shopping for a New York State health insurance plan.

Are Your Doctors In-Network – Before purchasing a health insurance plan you should always make sure that your doctor(s) are part of the network. Going to an out-of-network doctor may cost substantially more than if that doctor is in-network. Don’t just ask the doctor’s office if they accept a certain insurance plan before you enroll. You should always confirm with the insurance company or an agent that your doctors are in-network. Why the concern? Well, keep in mind that if an out-of-network provider suggests services, then all of those services provided by that recommended doctor will be considered out of network, even if the facilities and providers are in-network

Lower Monthly Premium May Result in Higher Costs– Health insurance follows a simple formula: the lower your monthly premium is, the more likely you are to pay higher costs when you use the insurance. If you’re someone who happens to be in good health and does not foresee any health-related issues and doesn’t use medicine on a very regular basis, then perhaps you’re better off opting for a lower costing health insurance plan. However, if you find that your medical expenses and prescription usages are high, then you may save money by purchasing a plan that costs more per month. Be sure to consider your current health condition when shopping for a health insurance plan. 

Health Insurance is a Contract – When purchasing a plan, both parties agree to live up to the contract (usually for a period of one year). If you find that you are not happy with your plan, you can’t go back to your insurance company mid-year and ask them to change coverage. You’ll have to wait for your contract to expire. Additionally, if you buy an individual health plan on your state exchange or through healthcare.gov and you allow that plan to lapse or you stop coverage, then you don’t qualify to buy a health plan on that exchange for the rest of that calendar year. As such, be sure to choose the right plan that suits your needs before signing the contract. 

Types of Insurance Coverage – EPO, PPO, POS, HMO, HDHP and HSA. The first 4 are acronyms that describe different types of health insurance coverage, which provide you with or without the flexibility to see specialists and receive out-of-network and out-of-state care. Also, different plans have different requirements related to the need for referrals. If you’re often seeing specialists out-of-network then you want a plan that offers that flexibility. If you find that you travel often for work or live in multiple states per year, then perhaps a plan that offers that flexibility is needed. The last two types, HDHP and HSA’s allow you to set up a tax-free savings account specifically for qualified medical costs For a better understanding of these types of coverage please refer to the following article.

Metal Levels –In order to make shopping and comparing health plans easier, a metal system to represent different insurance coverage levels was created. These insurance levels are grouped into 4 metals based on actual metal value. Bronze, silver, gold, and platinum all represent the metal worth and the level of coverage offered under each metal plan. In theory, a bronze plan will cover 60% of your medical costs and provide you with a maximum out of pocket dollar amount that does not equal the remaining 40% but instead is a threshold set for most bronze plans. Silver is set at 70%, Gold 80%, and the most valuable metal platinum is set at 90%. Based on your medical needs you should be able to relatively compare an appropriate metal level. For example, if you find that you have minimal health insurance needs then perhaps a bronze plan would best suit you. However, if your health status requires a good deal of care, then perhaps a gold or platinum plan, which costs more, will actually cost you less in the long run.

Are Essential Health Benefits Covered? – One way of ensuring the plan you purchase or intend to purchase covers the 10 essential health benefits, is to buy an on-exchange plan. All exchange plans must cover 10 essential health benefits. This provides you with a guaranteed minimum level of coverage, which is the standard set by the Affordable Care Act. Why would we need a minimum standard level? Well, the cost of medical care is prohibitive without insurance in place and can often lead to financial ruin. Ensuring that a plan includes the minimum essential health benefits provides a safeguard.

Premium, Deductible and Out-Of-Pocket Costs. Each term relates to the cost of using and maintaining your plan.

Premium is the cost of the insurance that you usually pay on a monthly basis to the insurance company. Premiums are often locked in for a period of one year, meaning the insurance carrier cannot arbitrarily charge you a higher premium within that year

Deductible is a yearly dollar threshold that you must meet prior to the insurance company paying for medical services. This almost always excludes preventative care.

Out-of-pocket costs are the maximum annual dollar amount that you can spend on health care services and medicine.

Health Insurance Subsidies A Subsidy is a dollar amount provided by the federal government paid directly to your insurance company based on your current yearly income. This money does not have to be paid back, however, if your income does increase, there is a strong possibility that your subsidy may change, which would then increase your monthly premium (retroactively). Conversely, if your income decreases within the year, that may reduce your monthly premium at which point you have the right to contact your insurance company and inform them of your income change.

Essential Health Benefits

What Are Essential Health Benefits? Essential Health Benefits are a set of 10 health care benefits established by the federal government under the Affordable Care Act of 2014. The purpose is to ensure that all persons are covered by a set of minimum standards. Specific insurance services may vary by state and all plans must provide dental coverage for children.

1.Ambulatory Patient Services – Medical care provided without admission to a hospital, including doctor’s office visits, clinics, and outpatient surgery centers.

2.Emergency Services – Organizations that are responsible to deal with emergencies when they occur. This includes medical care that if not treated could lead to serious conditions or disabilities.

3.Hospitalization – Medical care that patients receive when they are hospitalized. This includes the care of nurses, doctors, and other staff. This also includes medication received, room and board, tests and laboratory work.

4.Maternity – Medical care that a woman receives during pregnancy and post pregnancy. This includes labor, delivery, post delivery and the care for newborn babies.  

5.Mental Health Services and Addiction Treatment – Patient care provided to evaluate, diagnose, and treat any mental health conditions or substance abuse disorders.

6.Rehabilitative Services and Devices – Services provided after an injury, accident, disability, or a chronic condition. The purpose is to attempt to help regain the patient’s mental and/or physical skills that were lost (to make the person whole again).

7.Pediatric Services – Medical care that is provided to children and infants, including regular check-ups, recommended vaccines, dental and vision care.

8.Prescription Drugs – Medicine that is prescribed by a doctor, and nurse practitioner, to treat any illness or existing condition.

9.Preventative and Wellness Services and Chronic Disease Treatment – Physicals, Immunizations, and cancer screenings to prevent or detect certain medical conditions, and to provide care for chronic conditions.

10.Laboratory Services – Medical tests that are usually ordered by your doctor which include coverage for X-Rays and diagnostic imaging, blood and fluid tests, biopsies, pathology, and pregnancy tests.

Which Types of Insurance Plans are Not Required to Cover the Essential Health Benefits? The following insurance plan types are not required to include essential health benefits and most often don’t.

Short Term Medical Insurance

Accident

Critical Illness/Cancer

Hospital Confinement

Association Health Plans

Faith-Based Healthcare

Large Group Insurance plans (50 employees or more)

Travel Insurance

Dual Citizenship insurance (As long as you have proof of Identification)