Health Insurance Open Enrollment:
You Have Options

Rising medical costs and healthcare reform laws make now a great time to reeducate yourself about health insurance. Here are some tips, whether you are shopping for new coverage or renewing an existing policy.

  • Know your options: Don’t automatically renew the option you had before. Plans change, and so may your options and needs from year to year.
  • Review costs: Compare policies and their costs to see what fits your needs. Look beyond the monthly amount you must pay and closely evaluate covered services, co-pay requirements, deductibles and reimbursement levels so that you make the best choice for your family and your pocketbook.
  • Understand your coverage: No new insurance plan sold can reject you, charge you more or refuse to pay for essential health benefits for any condition you had before your coverage starts. Once you’re enrolled, your plan can’t deny coverage or raise your rates based only on your health.
  • Tax penalty: If you can afford health insurance but choose not to buy it, you must pay a fee when you file your federal tax return for each year you don’t have coverage.

Employer Coverage: If you receive health insurance through an employer, consider the following before selecting a coverage plan each year:

  • Ask questions: Talk to your benefits administrator or insurer to understand your coverage and cost.
  • Wellness incentives: Find out if your employer offers a wellness program that includes money-saving incentives for healthy behaviors such as exercising regularly or not smoking.
  • Tax-free savings: In addition to your health insurance coverage, you may be eligible to open a Flexible Spending Account (FSA), health savings account (HSA) or dependent care savings account.

Individual Coverage: If you are self-employed or if your employer doesn’t offer coverage you still have choices.

  • Private insurance: Shop around to different insurance carriers to customize care to fit your lifestyle and budget.
  • Check out the exchange: Health insurance marketplaces or exchanges, operate in every state. These online portals ask a series of questions to determine which plans meet your needs. They also determine if you are eligible for any subsidies or alternative coverage through Medicaid or the Children's Health Insurance Program (CHIP).
  • Agents and Brokers: An agent or broker can help you purchase health insurance directly from an insurance carrier or through your state exchange.
  • Family Coverage: Check and see if you are eligible to be added to your spouse’s or domestic partner’s employer plan. Weigh your choices against purchasing individual coverage.

If you are unemployed within the past year you were likely forced to determine how, or if, to continue your health insurance. If you’ve been out of work for some time and your income has taken a significant hit, you or your family members might be eligible for Medicaid or the Children’s Health Insurance Program.

There are several types of health insurance.

Major medical plans typically cover a comprehensive array of healthcare needs, including doctors’ visits, drugs and hospital care. These benefits can be delivered in several different ways:

  • Indemnity plans – These major medical plans typically have a deductible – the amount you pay before the insurance company begins paying benefits. After your covered expenses exceed the deductible amount, benefits usually are paid as a percentage of actual expenses, often 80 percent. These plans usually provide the most flexibility in choosing where to receive care.
  • Preferred Provider Organization (PPO) plans – In these major medical plans, the insurance company enters into contracts with selected hospitals and doctors to furnish services at a discounted rate. As a member of a PPO, you may be able to seek care from a doctor or hospital that is not a preferred provider, but you will probably have to pay a higher deductible or co-payment.
  • Health Maintenance Organization (HMO) plans – These major medical plans usually make you choose a primary care physician (PCP) from a list of network providers. Your PCP is responsible for managing your entire healthcare. If you need care from any network provider other than your PCP, you may have to get a referral from your PCP. Treatment received outside the network is usually not covered, or covered at a significantly reduced level.
  • Point of Service (POS) plans – These major medical plans are a hybrid of the PPO and HMO models. They are more flexible than HMOs, but require you to select a PCP. Like a PPO, you can go to an out-of-network provider and pay more of the cost. However, if the PCP refers you to an out-of-network doctor, the health plan will pay the cost.

Additional coverage options provide added protection should you become disabled, require long-term care or enroll in Medicare:

  • Disability Income – This coverage provides for weekly or monthly benefit payments while you are disabled after a covered injury or sickness.
  • Long-Term Care Insurance – This policy usually pays for skilled, intermediate and custodial care in a nursing home, as well as care in other settings such as the home, adult day care center or assisted living facility. The policy usually pays a fixed amount per day while a person is receiving care.
  • Medicare Supplemental Coverage – The federal Medicare program pays most medical expenses for people 65 or older, or for individuals under 65 receiving Social Security disability benefits. However, Medicare does not pay all expenses. As a result, you may want to buy a Medicare supplement policy that helps pay for certain expenses, including deductibles not covered by Medicare.

The following are two types of health-related services that are NOT health insurance plans:

  • Discount Plans You may receive advertisements from plans offering discounts on healthcare for a monthly fee. These are not health insurance plans, and participants do not have the same protections as under licensed health insurance. Your insurance commissioner strongly recommends that you thoroughly investigate any plan promising deep discounts for a “low” monthly fee and weigh the benefits against the costs.
  • Non-Licensed Risk-Sharing Plans You may receive offers to join a group or association that will take your monthly payments, put them in a savings account or trust with other participants’ money, and then help pay some of your health care costs, as needed. Such arrangements are NOT insurance and the participants do not have the protections available to purchasers of licensed insurance plans. Your insurance commissioner strongly recommends that you thoroughly investigate such plans before joining.

Health insurance – whether provided by your employer or purchased independently by yourself – can be expensive. Here are some ways you can control your costs:

  • Stay in-network as much as possible for care, making sure to obtain referrals as required.
  • Many plans require pre-certification for certain tests and procedures. Know your plan, and make sure you comply with these requirements to avoid paying penalties.
  • Hold onto all receipts for medical services. Even though your intent may be to always stay in-network, you never know when an accident, out-of-town emergency room visit or unexpected illness might cause you to incur out-of-pocket expenses that exceed even a high deductible.

Health Insurance for Your Life Stage

In addition to your work situation, your family structure and lifestyle also have an impact on your health insurance needs. Find the right fit for you.

  • Young Singles: If you’re a recent college graduate entering the workforce, this is likely the first time you’re making your own health insurance decisions. You will have questions. What’s the difference between an HMO and a PPO? How long can you continue coverage on your parents’ health insurance policy?
  • Young Families: A new spouse or baby can significantly change your health insurance needs and costs. In short, it’s not just about you anymore. Consider these tips to ensure you and your growing family is covered.
  • Established Families: As your family matures, so do your health insurance needs. From maintenance drugs and braces to insurance for your college student, it’s important to know the facts.
  • Seniors and Boomers: Now that your children are grown, it’s more important that you focus on your own health. Make sure you have the right coverage before and during retirement.

Many other special health insurance considerations come into play for domestic partners, single parents, military, and seniors who are raising grandchildren. Knowing your options helps you save time, money and frustration.

Visit the NAIC's Special Section: PPACA & State Insurance Regulation for the latest news regarding healthcare reform implementation efforts.

Visit HealthCare.gov for information from the U.S. Dept. of Health & Human Services (HHS).

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