Premiums on state health insurance marketplaces are going up in many (but not all) states in 2017, and employer plan premiums are also creeping up, so open enrollment this year may seem extra stressful. Go into it armed with information on what to look for and which personal factors to consider in order to compare plans.
Here are five essential do’s and don’ts that will guide you to the best health insurance plan for you and your family.
1. Do shop around if your premium is going up. This is especially critical for the 20 million Americans who buy health coverage directly from insurance companies instead of getting it through an employer, Medicare, or Medicaid.
If your plan has told you your premium is going up, immediately hop on your state’s health marketplace to shop for a better deal. And be sure to use the marketplace’s online tools to find out whether your household might qualify for a subsidy to lower the price of premiums. New research finds that millions of people who are entitled these subsidies aren’t getting them because they don’t realize it.
Bear in mind that you can only claim the subsidy if you buy your plan through your state’s marketplace. This year, open enrollment on marketplaces started Nov. 1 and runs through Jan. 31, 2017.
2. But don’t shop by premium alone. A plan with a lower-than-average premium will usually have higher out-of-pocket costs such as deductibles and copays. A low-premium plan with a $4,000 deductible may put health care out of reach if you don’t have that much cash to spare.
So before you choose, look closely at what you’ll have to pay for specific services over and above the premium. This year, consumers in the 39 states whose online marketplaces are run by Healthcare.gov have a new tool to help for this; when shopping for a plan, you can elect to see your projected total annual cost—premiums plus out-of-pocket spending—depending on whether you expect to be a high, medium, or low user of health-care services.
3. Do make sure your doctors are in the plan’s network. This can be a challenge because network directories aren’t always up to date—if you can even find them. Healthcare.gov has a useful new tool for this as well.
When searching for a plan you can enter the names of doctors and hospitals you care about, and your results will call out plans in which they participate. But before you sign on, verify directly with the insurer. If your state-run marketplace or employer options don’t offer this feature, first look at the insurer websites for a directory, and then double-check directly with the company.
Asking doctors what plans they participate in isn’t as helpful as you might imagine. If, for instance, they say they “accept” Blue Cross, it may or may not be the specific Blue Cross plan you are considering. For best results, don’t ask a doctor or nurse; ask whoever in the practice handles health insurance claims and billing.
4. Don’t forget drug formularies. These are the lists of drugs that health plans cover, typically in “tiers”—the higher the tier, the more you’ll have to pay out of pocket. And formularies can change from year to year. If you routinely take prescription drugs, spend as much time as you need to determine whether they’re on the plan’s formulary, and at what tier of coverage.
Healthcare.gov is on top of this, too. When searching for a plan you’ll be offered the chance to enter drugs you take, and the results will tell you which plans include them on their formularies. If you’re insured through your employer, you may have to ask the benefits department for a link.
5. Don’t worry that whole categories of care won’t be covered. All plans sold directly on marketplaces must cover all “essential health benefits,” including hospitals, prescription drugs, outpatient procedures and office visits, and rehabilitation, mental health, maternity, emergency, and preventive services (think immunizations, screening mammograms, and colonoscopies.
Employer plans have slightly more leeway on what specific services they include but will also cover the same broad categories of benefits.
Nancy Metcalf is an award-winning independent journalist specializing in health topics. A senior writer and editor for Consumer Reports for more than 25 years, she is a nationally recognized expert on health insurance and health reform.