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Utilizing an experienced broker is also critical. You'll receive valuable free advice from a resource that represents all major carriers. Verifying that your doctor, specialist, or hospital is "in-network" is just one of the many important services that we (experienced brokers) provide. And having a clear understanding of how your prescription coverage will be treated is also quite important.
Now that the ACA legislation has been passed, and single and family healthcare coverage is so different than prior to 2014, it's imperative to work with an experienced broker that can help you understand which plans best meet your budget and still offer the comprehensive (or catastrophic, if needed) benefits that will pay your medical bills.
Another important factor is the accurate calculation of your federal subsidy. Depending upon your FPL (Federal Poverty Level), you may qualify for financial assistance that pays most or all of your premium.
Understanding network availability is also critical when reviewing different plans. If you live in Ohio, for example, is the Cleveland Clinic a covered provider? That's the type of information that must be considered along with the obvious rate and benefit concerns.
IMPORTANT: The answer to this question was provided by Edward Harris, one of the nation's premier health insurance experts with more than 34 years of experience. Harris manages several top-rated websites, including majormedicalhealth.com, which provides the lowest health insurance rates to consumers from the largest carriers. Our clients receive unbiased service and advice at any time.
Web sites, whether they are Healthcare.gov or insurance agent or insurance carrier based can only go so far. Buying health insurance isn't like buying a hotel room online, as a lot of people who enrolled themselves through Healthcare.gov have painfully learned. The bottom line is that you should seek out an experienced health insurance agent who represents multiple health insurance carriers and who is certified to sell coverage through Healthcare.gov or your state's health insurance marketplace.
You can no longer assume that your doctor is available as an in-network provider with every health insurance plan offered by a health insurance company that you think you are familiar with. For instance, here in Tennessee the Blue Cross/Blue Shield plan offers identical looking health plans through Healthcare.gov with three different PPO networks each of which has a different price point. The lower the monthly premium gets the narrower the provider network gets. Human nature is to gravitate towards the lowest cost plan if the benefits look the same and that's fine until you find out your long time doctor doesn't participate in that product's network. In the world of ObamaCare once you've enrolled and the open enrollment period has closed you are stuck with your plan selection until next year's open enrollment.
If you are using specific prescription medications you really need to do your homework there and that's where having professional guidance is so crucial. You should verify if your medication is covered in the prescription formulary of any health insurance carrier you are considering. Then, if it is covered, at what tier level in the pharmacy coverage is it covered? Will the insurance carrier require you to get reauthorized to continue using that medication or require you to reinvent the wheel and go through what is referred to as step therapy where you may have to try to use other, less expensive medications to treat your condition before you are allowed to continue using your current medication? These are all real possibilities and I haven't come across an individual consumer yet who figured these things out on their own.
What coverage does the insurance plan you are considering offer if you want to go outside of their network? Some health insurance brands you may have been familiar with in the past have totally reworked their individual insurance products so as to provide little or no out-of-network coverage. What is the health insurance plan's policy on access to facilities such as M.D. Anderson, the Mayo Clinic and other such nationally prominent specialty health care providers? You should not assume that all health plans will allow access to such facilities. If you have a chronic health problem or have had a family history of health issues where access to such facilities might be important to you, it's better to figure that out in advance.
THIS ANSWER WAS PROVIDED BY: Marlin McKelvy, a Chartered Benefits Consultant with 30 years of industry experience and a web site at www.cdbsagency.com but who is committed to providing personalized advice and guidance because an informed client is a happy client.
I'd ask you to contact one of the advisers available on the site, or a qualified agent to help find the right policy for you, but here are some simple things that you can look at to get an idea. ( I have simplified this greatly)
The OUT OF POCKET COST - this is what it will cost you to get your service, Doctor visit, or service. The out of pocket is determined by your DEDUCTIBLE ( the amount that you pay before the insurance company pays - a high deductible plan will cost less in monthly premiums, but more when you need medical help), your CO-PAY, (the amount that is charged to you for the service rendered. Typically, the lower your out of pocket, the higher your monthly premium will be. If you/your family are healthy people with few prescriptions or medical needs, a high deductible plan with a low monthly cost might make sense.
The PREMIUM - this is the monthly cost of the policy that you will pay to the insurance company for the coverage the policy will provide.
The COVERAGE - what the policy will allow for services, Doctors, and prescriptions. Here's where an adviser can be really helpful. You want the policy that covers the most things for the least cost, while allowing you the most freedom over who to use as the provider of the services. If you have a medical need that requires frequent services, and you've had the same Doctors for awhile, you'd want to be sure that the policy allows that doctor to continue being your Doctor (They call this in-network, or out-of-network and charge accordingly), and that his/her office accepts that insurance.
This is a greatly simplified overview, and I would still advise that you have someone help you when you are choosing, but this hopefully gives you a better idea of how to get started. Thanks for asking!