Solving Your Insurance Puzzle

Along with cooler weather and autumn leaves, this time of year for most people brings open enrollment for health insurance. Depending on where and how you get your insurance, open enrollment may last from a few weeks to a couple of months, and your choices this year will affect your health and your pocketbook until you ring in 2023. This information can help you make decisions that are right for you. 

If your employer offers coverage… 
If you get insurance through your employer and have more than one option, carefully compare costs and benefits – even if you are happy with your current plan, says Nick Turkas, director of Help and Support for the Arthritis Foundation. Health plans and situations can change, and the plan that served you well last year could leave you with high medical costs this year.

It may be tempting to choose the plan with the lowest monthly premium, but other costs can outstrip premiums. Make a list of your providers, medications and anticipated medical expenses for the upcoming year. (Find costs for procedures and services in your area at your insurance provider’s website, or try fairhealthconsumer.org or healthcarebluebook.com.) 

When choosing a plan, weigh the following factors:
Premium. The price you pay monthly for the insurance policy.

Deductibles and coinsurance. The deductible is the amount you must pay toward your care before insurance starts paying. Coinsurance is the percentage you must pay after the deductible has been met. Both can be significant expenses, but choosing a lower deductible or coinsurance will require a higher monthly premium.

Health and Flexible Savings Accounts. With a high-deductible plan, you may be able to set up a Health Savings Account (HSA), which allows you to set aside a certain amount of pre-tax money for medical expenses, including deductibles and copays. A Flexible Savings Account (FSA) also allows you to set aside a certain amount of pre-tax money for medical expenses, but the limit is lower than for an HSA. And, unlike an HSA, you must use your FSA funds by the end of the annual policy or lose what’s left.

Out-of-pocket maximums. This is the most you will have to pay (excluding premiums) for health care during the plan year – assuming you don’t go out of network for any care (see below). If you anticipate high costs, a lower out-of-pocket max is worth considering.

Covered providers. Some plans require you to use their own providers; others allow you to choose, but pay or reimburse you less if you choose a provider who’s out-of-network, which means higher cost to you. Check with your providers to see if they are covered by the plan you’re considering. “This means not only your primary care doctors, but rheumatologists and specialists you see for other chronic health conditions,” says Turkas. If you are planning some non-routine treatment for 2022, such as joint replacement surgery, make sure those procedures and providers are covered, too.  

Drug formularies. This is the list of drugs your insurance plan covers. Find out if the drugs you and your family take – and those your doctor is considering for you – are on the list. Be aware that there may be a separate deductible for medications and that formularies may change during the plan year, so a drug that is covered now may not be covered in six months.

Other coverage. Compare the plans’ coverage for surgery, physical therapy, rehabilitation, durable medical equipment, assistive devices or any other need you anticipate for the upcoming year. 

You’ll likely need more information than the enrollment materials provide. Your employer’s human resources department can help you find the facts you need. Contact providers directly to confirm their participation in a plan. 

If your employer’s plans are expensive or don’t suit your needs, you can refuse coverage and shop for a plan on state or federal exchanges (aka: the Marketplace), says Matthew Lombard, a customer associate with JOANY, a health care concierge service that helps consumers compare plans, find doctors and get help with medical bills. He recommends shopping the Marketplace first, because once you refuse coverage through your employer, you won’t have a chance to get it again until the following year’s open enrollment.

If you’re going it on your own… 
You may be able to find a good plan through your state or federal exchange (start your search for either at healthcare.gov) or by going directly to companies that provide individual insurance, says Lombard. When shopping for a plan, consider the same factors as for an employer-provided plan.

A benefit of using the Marketplace is that if you meet certain income requirements, you may qualify for subsidies, which are paid directly to the insurer and lower your premium. Recent funding cuts may affect the subsidies, however. Furthermore, any plan you choose through the Marketplace must comply with the Affordable Care Act, meaning it must provide 10 essential benefits (including preventive care and medications), it has no lifetime maximum payout (a plan that is not ACA-compliant may limit the total that it will pay) and it cannot deny coverage for a pre-existing condition. 

A downside is that costs can be quite high. If you earn more than the income limits for subsidies, which are strict, you could potentially pay thousands more per month for coverage.   

A licensed broker or an assistant with healthcare.gov can help you sort through the options, although funding cuts also may reduce access to these services. Private organizations such as JOANY and Stride Health (stridehealth.com) can help you pick the best plans for your needs and determine your overall costs. These services are free, and anyone can use them to find the best options for their situation.

If you’re eligible for Medicare…  
Your first open enrollment for Medicare is three months before you turn 65. Subsequent open enrollments begin in October each year. 

When selecting a Medicare plan, your primary choice is between traditional Medicare or a Medicare Advantage plan. Traditional Medicare comes in two parts: Part A is hospital insurance, and Part B is medical insurance. Medicare Advantage, sometimes called Part C, is offered by private companies and may offer benefits such as routine vision or dental coverage that traditional Medicare does not provide. Medicare Advantage plans also cover prescription drugs; this is different from traditional Medicare, in which people have the option of signing up for a prescription drug plan (Part D) for drug coverage. 

Medicare or Medicare Advantage?
Whether original Medicare or Medicare Advantage is better for you depends on a number of factors.

“Enrollment in Medicare Advantage has been growing steadily, in part because the coverage tends to look similar to benefits an individual received through an employer during his or her career,” says Vincent Pacileo, the Arthritis Foundation’s director of federal affairs.  

However, Medicare Advantage can be restrictive. While traditional Medicare covers a doctor or service anywhere that accepts Medicare, private insurers administer Medicare Advantage, so benefits vary depending on the plan. For instance, provider networks in Medicare Advantage plans may not include all of your doctors. Similarly, in some cases these plans may limit networks to certain geographic areas, so it is important to understand the plan’s full scope of benefits before enrolling.  

Since traditional Medicare doesn’t cover all costs, if you choose it, you might also want a supplemental policy, called Medigap, through a private insurer to help with deductibles, coinsurance or other medical care, says Pacileo.

You can get personalized health insurance counseling for Medicare at no cost to you from your local State Health Insurance Assistance Program (SHIP), shiptacenter.org.

If you think you’re out of options… 
If the costs of plans through your employer or the Marketplace have you wondering how you can pay your premiums, you may be tempted by less expensive options. Beware. The prices for ACA-compliant health plans are fixed by law, so if you think you’ve found a better deal, you may not get the coverage you’re counting on.

Here are a few noncompliant plans you might find:
Fixed indemnity plans. They pay a set (and usually small) amount for each doctor visit, prescription or day in the hospital, regardless of the actual cost. The remainder – which can be pretty hefty – is up to you. 

Short-term plans. These are typically offered for three-month terms. In some states you can purchase four policies back-to-back to get “coverage” for an entire year. But the deductible starts over after each three-month period, and a health problem you develop during one three-month policy could potentially be considered a pre-existing condition under subsequent ones. 

Health care sharing ministries. Offered as an alternative to health insurance, these programs allow individuals and families to contribute to a pool of cash that is used to pay one another’s health care costs. Your monthly “share” goes into a credit union account from which members’ medical bills are paid. The types of costs covered are often very limited. 

It’s important to note that none of these typically pays for preventive care or mental health, and some do not pay for pre-existing conditions, or they limit how much they will pay.

Many insurers and brokers offer plans that are not ACA-compliant (and you don’t have to wait until open enrollment to get one). But before purchasing one, understand the limits and options. A plan that might work for the rest of the family may not be the best choice for someone with a chronic condition, like arthritis. 

When choosing – and using – your insurance policy:

• Compare pharmacy options before signing up; don’t assume mail-order pharmacies are cheaper.
• Ask your pharmacist if your medication would be cheaper if you didn’t use insurance. (This would not count toward your deductible.) 
• Look for financial assistance programs at arthritis.org/ATpayingfortreatment. (Medicare and Medicaid recipients may not be eligible for co-pay card discounts.) 
• Don’t assume your doctor knows your plan limits.
• Keep track of paperwork.