Tips for Choosing the Right Health Care Plan

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Choosing a health care plan for you and your family can be overwhelming. There's so much to consider, it almost seems like an impossible task. Thankfully, there are some incredibly helpful tips available to assist in your decision making as enrollment gets underway. To learn more, we got in touch with Carrie Kincaid, Senior Vice President of Market Development for Priority Health for her insight.

First, Kincaid notes there are two key enrollment periods, depending on the type of coverage you need for you and/or your family, to be aware of.

"For those eligible for Medicare (ages 65 and up), the annual enrollment period (AEP) to enroll in a Medicare plan is October 15 through December 7," she said, explaining the open enrollment period for individual and family health plans is November 1, 2022 through January 15, 2023. "This period, also known as 'OEP,' is the annual period of time when individuals can enroll in a qualified health plan either through the federal marketplace (healthcare.gov) or a private insurer like Priority Health."

Thankfully, the experts understand health insurance can make most people's head spin. Kincaid shared this quick guide to health insurance terminology as you shop.

Deductible. The amount you pay out-of-pocket for covered health care services before your health insurance provider begins to pay.

Premium. The amount you pay to have health insurance, which is usually paid monthly, quarterly or yearly by you and/or your employer.

Copayment. A fixed amount you pay for a covered health care service each time you receive it. The amount can vary depending on the type of service. You often may hear this referred to as a copay.

Coinsurance. Sometimes the cost for your medical services is shared between you and the health insurance company. Coinsurance is calculated as a percentage of the total cost you must pay above and beyond your copay. For example, you may be responsible for 20% of the cost, while the insurer covers the remaining 80%.

Provider network. A network of providers who are contracted to provide health care services to plan members. An in-network visit is often less expensive as the health insurance company and the provider have negotiated lower rates.

Formulary. A list of prescription drugs covered by your insurance plan.

Out-of-pocket limit. The maximum amount you pay out-of-pocket for covered services in a year.

It's important to understand that what's "right" for one individual or family isn't necessarily the best choice for the next. Kincaid notes these factors are often dependent on your health needs and lifestyle, but ultimately the "right" plan should ensure you have coverage and care that is accessible, affordable and excellent.

Understand what's available to you.

"Many people get their insurance through employers, but if you are self-employed or your employer doesn't offer health insurance, you can shop the federal marketplace or purchase directly from an insurer, for both Individual and Medicare plans," Kincaid said.

From there, decide which type of health plan is best for you and your family: An HMO, PPO or a Medicare Advantage or Medigap plan.

"Have a conversation about whether you want an HSA (Health Savings Account) eligible plan," Kincaid advised. "An HSA Plan allows you to open a health savings account to save for future medical expenses tax free upon filing your taxes. HSA plans paired with an account can help families manage the yearly deductible expense."

Understand the plan's network.

"Be sure to check to see if your preferred doctor is in the plan's network, and consider which hospitals and facilities are important for you to have as in-network," Kincaid said.

Kincaid emphasizes some key factors in shopping for a health care plan.

Familiarizing yourself with the different types of plans offered is essential to understanding your coverage options. Understand the difference between in network and out of network coverage, in addition to the difference between levels of plans.

"If you're relatively healthy and don't visit the doctor often, knowing the difference between a bronze and a gold plan could save you from paying a high premium for broader, richer coverage that you may not necessarily need," Kincaid said.

Because you may be eligible for financial assistance, Kincaid suggests planning ahead to ensure you get the most savings.

"If you purchase your own health coverage, you may be eligible for additional savings," she said. "APTC (Advanced Premium Tax Credits) are available to nearly 80% of enrollees and can significantly reduce the amount of monthly premiums you and your family will pay."

An additional form of financial assistance includes CSR (Cost Share Reductions), which Kincaid explains are available to about half of enrollees when they choose to purchase a silver product.

"They significantly reduce your deductible, out of pocket maximums and copays," she said. "You can see if you are eligible for APTCs and CSRs at mypriority.com or healthcare.gov."

Early research and comparing plans can help you avoid last-minute stress.

"If you don't purchase a health plan before the enrollment deadline, you might have to wait an entire year to apply for coverage unless you experience a qualifying life event, like getting married or having a baby," Kincaid said. "Shop early and avoid the stress of looming deadlines."

Much like any big purchase, Kincaid says it's important to do your research, as selecting the right health insurance plan takes time. Pay attention to:

  • Type of plan and provider network. "Do the health care providers, hospitals and pharmacies you prefer fall within the plan's network?"
  • Premiums, deductibles and copays. "How much will you pay per month for coverage and what is the amount you must pay out of pocket before your coverage kicks in?"
  • Medication. "Check to make sure your regular prescriptions are covered."

"Consider a plan that fits your lifestyle, perhaps a virtual-first plan or one with unique travel benefits," Kincaid suggests. "If you have a chronic condition, find a plan that offers access to necessary services, supplies and treatments for free or reduced copays ahead of deductible."

Overall, Kincaid stresses the importance of not going uninsured.

"Having health coverage is vital and necessary, regardless of your age and health status," she said. "It covers essential health benefits critical to maintaining your health and treating illness and accidents."

You can visit the Health Insurance Marketplace at healthcare.gov and Priority Health at mypriority.com to learn more about your options.

"If you have additional questions, reach out to an enrollment specialist," Kincaid said. "Priority Health employs a local, Michigan based team that offers guidance and can answer questions."

Written by Sarah Suydam, Managing Editor for West Michigan Woman.


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