Factors to Consider When Comparing Insurance Options

Choosing an insurance plan can be overwhelming. Here are a few factors to consider during Open Enrollment.

Choosing an insurance plan can be overwhelming. Here are a few factors to consider during Open Enrollment.

Shopping for a health insurance plan can be overwhelming. Where do you start? You start with your needs: health, lifestyle, finances, and estimating the unexpected. Set aside time for this because it’s for your health, literally. Some types of plans may seem crazy to choose for yourself but perfect for another person. Also, keep in mind that what might appear expensive might save you money in the long run so estimating what you would actually spend on healthcare next year is a priority before figuring out which plan will spare your finances the most while not sparing your needs.

There are numerous factors to consider, but ask yourself the following:

  • Do I plan on starting a family next year?

  • Are there medications I need and are they only brand or generic?

  • Do I have a favorite physician or a specialist I trust?

  • How often did I go the doctor last year?

  • Are there a lot of doctors and hospitals to choose from?

  • What can I afford monthly and how much could I scrape together at a moment’s notice?

  • Will the amount I make qualify me for Medicaid? CHIP? or tax credits?

  • Do you want vision or dental?

  • Are you looking for alternative care?

These questions are really geared towards understanding...

  • How often you should anticipate visiting the doctor based on your needs and, if you have a family, your family’s needs

  • You might need a specific type of physician or one you trust

  • The cost of likely or unlikely operations: C-section, visit to the ER

  • If you should go with a plan that has a narrow or wide scope in choices of providers/hospitals

  • If you should go low premium & high deductible OR high premium & low deductible

Next, learn the lingo so you can match your needs to plan type: HMO, PPO, EPO, POS.

HMO (Health Maintenance Organization): You have a primary care provider who you will refer you to a specialist if necessary but you must always see your primary care provider first. These plans typically have lower premiums and lower cost-sharing.

PPO (Preferred Provider Organization): You can see any provider you choose, but keep in mind that not everything will be covered if you go out of network and it will be more expensive. These plans typically have higher premiums and higher cost-sharing.

EPO (Exclusive Provider Organization): In an EPO plan you can see anyone in-network without needing a referral, but if you go out-of-network you will have to pay the full cost. This plan typically has a lower premium and higher deductible.

POS (Point of Sale): With this plan, you are allowed to get out-of-network care under special circumstances but you will need a referral from your primary care provider. Cost of this plan is typically lower in-network and higher out-of-network.

You need to know how you’re going to pay, so here’s some more lingo: copay, coinsurance, deductible, out-of-pocket maximum, premium:

Copay: A fixed amount you pay per visit.

Coinsurance: A fixed percentage you pay per visit or procedure.

Deductible: The amount you must reach before your insurer begins paying for services. Up until that amount, you pay for services 100%.

Out-of-pocket maximum: This amount is the most you will have to pay for services for the year.

Premium: The monthly payment you make to keep your insurance. Usually, the trade-off is a low premium but a higher deductible and vice versa.

And if you really want to be thorough, every insurer will have a drug formulary which is a list of covered prescription drugs. If you have medication you regularly take it’s important to find out if the plan you’re looking at covers it. Some medications have exorbitant costs without insurance coverage.

I know this seems like a lot of work but take your time with it and ask questions, lots of them. All of these factors can add up to a terrific plan that can best serve your needs. Remember, Open Enrollment began on November 1st. Best of luck!

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