Am I Covered? 5 Tips to Make Sure You’ve Got the Right Insurance

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Got the Right Insurance

If you need health insurance, here is a double dose of good news. Open enrollment for individual health coverage is available through August 15, 2021, due to the coronavirus emergency. The economic stimulus legislation means most people will pay lower premiums this year even if they already have coverage. Buying health insurance can be confusing. You have to learn about deductibles and copays. Then there is the alphabet soup of HMOs, PPOs and so on. Below are some tips to make sure you’ve got the right insurance.

  • Know What’s Covered

Since the Affordable Care Act passed in 2014, all health insurance policies must include the following essential health benefits:

  • Prescription drugs
  • Pediatric services
  • Preventive and wellness services and chronic disease management
  • Emergency services
  • Hospitalization
  • Mental health and addiction services
  • Pregnancy, maternity and newborn care
  • Ambulatory patient services
  • Laboratory services
  • Rehabilitative and habilitative services and devices
  • Think About Your Needs

Before you shop for insurance, think about how you and your family use medical care. A plan with a higher monthly premium, but lower out-of-pocket costs might work if you:

  • Frequently see a doctor
  • Visit the emergency room often
  • Are pregnant or plan to get pregnant
  • Have surgery planned
  • Regularly take brand name medications
  • Receive treatment for a chronic condition like diabetes

Select a plan with lower premiums, but higher out-of-pocket costs if you:

  • Are in good health and rarely see a doctor
  • Need to pay lower monthly premiums
  • Work with Networks

Health insurance plan types differ based on how much freedom you have to choose your doctor. Below is an overview on different types of health insurance plans:

Exclusive Provider Organization (EPO): covers services only if you use providers who are in the plan’s network. 

Health Maintenance Organization (HMO): will not pay for doctors unless they are part of the HMO. Out-of-network care is not covered except in an emergency. 

Point of Service (POS): with this plan, you pay less if you use doctors and services that are in-network. You’ll need a referral from your primary care doctor to visit a specialist.

Preferred Provider Organization (PPO): your cost is lower for providers who are in the plan’s network. You can use providers outside of the network for an additional cost. 

  • Compare Costs
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The monthly premium is just one cost to consider when buying health insurance. Other costs include the deductible, copayments and your out-of-pocket maximum. For an estimate of annual costs, use an online service for customized quotes, or you can go to HealthCare.gov to compare plans.

The deductible: is the amount you pay before your insurance coverage starts. With a $2,000 deductible, you pay for the first $2,000 in services yourself.

Copayment: or copay is a fixed amount, such as $20, you pay for a health care service after you’ve paid your deductible. For example, if a doctor’s visit costs $100, your copay would be $20 and the insurance would pay the rest. However, if you have not met your deductible, you will pay $100.

Coinsurance: some health services are not fully covered even after you reach your deductible. You pay a percentage, such as 20 percent, for care. Your insurance covers the rest.

Out-of-pocket costs: include anything not covered by insurance. Prescription medications that are not in your plan are an example. Deductibles and copays are part of this category.

If you’re looking for a reasonably priced plan, here are the elements that hold down costs.

  • Plans with high deductibles have lower monthly premiums. But you pay more when you see a doctor.
  • HMOs are typically the cheapest type of plan. However, they have the most restrictions on which providers you can see.
  • Be sure your primary care doctor is in the network you choose.
  • Insurers have a list of drugs they cover. Be sure your prescription medication is on the list or your insurer will not pay for it.
  • Understand Health Insurance Categories
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Whether you buy an individual plan through an agent or your state’s insurance marketplace, they come in four categories: Bronze, Silver, Gold and Platinum.

Bronze

  • You pay 40 percent, the insurer pays 60 percent
  • Copay – high
  • Deductible – high 
  • Premium – low

Silver

  • You pay 30 percent, the insurer pays 70 percent
  • Copay – moderate
  • Deductible – lower than Bronze
  • Premium – moderate
  • Silver plans are the only category eligible for cost-sharing reductions

Gold

  • You pay 20 percent, the insurer pays 80 percent
  • Copay – low
  • Deductible – low
  • Premium – high

Platinum

  • You pay 10 percent, the insurer pays 90 percent
  • Copay – low
  • Deductible – very low
  • Premium – highest of all

Preventive care, such as an annual physical, is free in all plan categories even before you meet your deductible.

Making Sure You’ve Got the Right Health Insurance 

With these tips, you can confidently shop for health insurance during this year’s open enrollment period. Assess your healthcare needs and find the best-priced plan for your situation. Remember, the economic stimulus plan means lower premiums for most households.