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Choosing health insurance
 THRIVE! MAGAZINE
For many area employees, the period between Nov. 1 and Dec. 31 is health insurance open-enrollment season. It’s a bewildering time filled with important decisions and lots of jargon. Questions may be swirling in your head: What’s better: a high premium/low deductible, or a low premium/high deductible? HMO or PPO? Is co-insurance the same thing as co-pay or are they the completely different? What’s the difference between a flexible spending account, a health savings account and a health reimbursement arrangement? “Before you try understand what to buy, you have to understand the jargon,” says Jill Jones, a licensed clinical social worker at SLUCare. Jones daily helps patients understand the nuances of insurance. (A glossary of insurance terminology follows this article.) Once you understand the terminology, focus on exactly what you need in terms of care. “The best way to choose a health care plan is to balance what you can afford with the best coverage for the services you need or expect to need,” Jones says. “Remember, health insurance is for both everyday things and for ‘just in case.’ Being underinsured can make you feel as if you have no insurance at all, so choose carefully.” To help you make the best decision for your family, Jones offers these suggestions for what to consider before you sign on the dotted line. Make a list. Write out every service – every test, medication, doctor visit – that you expect every covered member of your family to need in the coming year. Using last year as a reference is a good place to start, but also consider life changes. Milestone birthdays may mean new tests, additional doctor visits, even changes in medication. Be careful about medications. Check to see where the medications you rely on fall within the health plan’s cost chart. A name-brand medication you take on your current plan may move to the top tier of a proposed plan, making it too expensive to take. If that happens, check with your doctor to see if a less expensive alternative exists or choose a plan that keeps your medication affordable. Consider family history. If diabetes or high-blood pressure runs in your family, your physician may want to run additional tests as you age. To be on the safe side, you can call your physician’s office and ask what tests may be in your future. You can also go to WebMD (webmd.com) and see what type of tests might be associated with the conditions that run in your family. Consider what happens if you need to see a specialist. Verify that the plan you are choosing will allow you to see an out-of-network specialist if necessary. Check to see if you’ll need a referral to do so and know up-front what the cost will be. Costs can rise when special care is required, so consider whether the plan you’re looking at has a maximum out-of-pocket limit and whether you can afford to reach it. “Getting straight answers just by reading the health-plan materials can be really hard,” says Jones, “but your employer’s human resources department should be able to answer your questions. If you want to talk to someone, get a direct number. Just calling the insurance provider’s main customer service number almost guarantees that you’ll be going round and round looking for answers.” Insurance Terms You Need to Know Co-insurance. The amount you must pay for medical care after you have met your deductible. The amount can vary from plan to plan. Co-pay. Flat fee you pay each time you receive medical care. Deductible. Amount you must pay each year before your insurance begins paying. Disability insurance. Insurance that pays benefits if you are injured or become seriously ill and are no longer able to work. Exclusions. Services that are not covered by a plan. Also called limitations, these service restrictions must be clearly spelled out in plan literature. Flexible spending accounts. Accounts that allow employees to set aside pre-tax dollars to pay for qualified medical expenses during the year. Unused amounts are forfeited at the end of the year. Formulary. An insurance company’s list of covered drugs. Group insurance. Health plans offered to a group of individuals by an employer, association, union or other entity. Health maintenance organization (HMO). Managed care in which you receive all of your care from participating providers. Typically, referrals are required before you can see a specialist. Health reimbursement arrangement. An account established by an employer to pay an employee’s medical expenses. Only employers can contribute to health reimbursement accounts. Health savings account. An account established by an employer or individual to set aside tax-free money toward medical expenses. Remaining balances “roll over” to the next year. High-deductible health plan. A plan that provides comprehensive coverage for high-cost medical events. It features a high deductible and a limit on annual out-of-pocket expenses. This type of plan is usually coupled with a health savings account or a health spending account. High-risk pool. State-operated program that offers coverage for individuals who cannot get health insurance from another source due to serious illness. Individual health insurance. Coverage purchased independently, usually directly from an insurance company. Long-term care insurance. Coverage that pays for all or part of the cost of home health care services or care in a nursing home or assisted living facility. Network. A group of physicians, hospitals and other providers who participate in a particular managed care plan. Point-of-service plan. A form of a managed care plan in which primary-care physicians coordinate patient care. Typically, this plan offers more flexibility in choosing doctors and hospitals than an HMO. Preferred provider organization (PPO). A form of managed care which gives you more flexibility in choosing health-care providers. You can see both participating and non-participating providers, but your out-of-pocket expenses will be lower if you see only plan providers. Premium. The amount you pay to belong to a health plan. Primary-care physician. Your first point of contact with the health care system, particularly in a managed care plan. Adapted from U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (ahrq.gov/consumer/insuranceqa/)
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