This is a fundamental question in the health insurance buying process. Healthy people who rarely see a doctor or visit a hospital can view health insurance more as a protection against catastrophic costs associated with unforeseen accidents and illness. Consequently, premium assumes a higher importance in the buying process for this group of people than issues such as breadth of doctor network and out-of-pocket costs charged for healthcare services.
People who use healthcare more frequently, on the other hand, have a much different set of considerations than the very healthy. This latter group should consider:
The following sections of this article address several of these questions in more detail. With that said, the answer to the question “Which Healthcare Services Do I Expect to Use This Year?” is fundamental for a consumer who wishes to make an appropriate and cost-effective health plan selection. It establishes the emphasis that should be placed on items such as cost-sharing, healthcare provider network breadth, and covered benefits.
Health plans differ in the benefits they cover, even for Affordable Care Act plans that have the requirement to cover 10 Essential Health Benefits. The definition of benefit scope and drug coverage included in the 10 Essential Health Benefits varies by state. Term Health Insurance plans, in contrast, have different levels of benefits even within the same state. This variation in benefits is a fundamental characteristic that differentiates Term Health Insurance plans from one another.
Because of variations in approved medications and health benefits among plans, it is important to confirm coverage of your anticipated healthcare and medications prior to enrollment. However, aside from getting benefits consumers know they will need, there are also decisions to be made regarding benefits that consumers may or may not need. Sometimes the relevance of these benefits are dependent on personal circumstances. For example, women of child-bearing years may be interested in maternity benefits while single men may not. Consumers may questions whether they should add additional vision care or dental coverage to their insurance needs. For consumers, some benefit decisions come down to the prospect of paying for additional benefits they don’t expect to use and the risk of facing high medical bills if the benefits are eventually needed but not included in their health plans.
Chronic conditions like congestive heart failure, a personal history of cancer, obesity are examples of pre-existing health conditions that should receive ongoing monitoring and care. People who live with health conditions like these should consider health coverage that 1) will not decline an insurance application due to these conditions and 2) pay for their ongoing care as a pre-existing condition. Affordable Care Act health plans will accept insurance applicants regardless of current health or pre-existing conditions. Term Health Insurance does not provide health benefits for health conditions that were present prior to coverage and may reject insurance applicants with many of those pre-existing conditions.
Some people select a health plan because they are familiar with the insurance company’s name. However, a well-known insurance company does not necessarily mean that its health plans are superior or that they are more competitive on price. In some instances, quite the opposite may be the case. Consumers should consider investigating health plan quality from sources such as National Committee for Quality Assurance before enrollment and not relying on the assumption that a well-known insurance company is a good insurance company. Talking to friends and relatives who have experience using the health plan being considered is also helpful.
For people who need to use certain doctors or hospitals, it is vitally important to confirm these healthcare providers are in-network before enrolling in a health plan. Healthcare services received from out-of-network providers for nonemergency situations may not be covered by a health plan. Practically, this means that the consumer is responsible for 100% of the costs in these scenarios.
Alongside the costs of out-of-network healthcare, consumer should be aware that annual limits on out-of-pocket expenses typically do not apply to out-of-network healthcare providers.
The costs of a health plan are more than premiums. When healthcare services are used, there are typically copayments, coinsurance fees, or deductibles to consider. For each health plan you are considering, the annual costs of premiums should be added to that plan’s annual out-of-pocket costs for the healthcare you expect to use. A low premium isn’t always a good idea if annual out-of-pocket costs exceed the amount you saved on a lower premium.
HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan.