Choosing a Health Plan That Fits Your Needs

Article by Alan Fijalkowski

It’s almost that time of year! The leaves change colors and begin to fall, the pumpkin-spiced everything hits store shelves, and open enrollment for health care elections begins. Open enrollment is a great time to review your health plan options to optimize and adjust benefits for you and your family. 

There are just as many variations in the health care availability and selection options as there are unique family needs, meaning every situation is different. The number of usual options can be overwhelming, and many families will choose a plan that may not be optimal for their needs. The best way to ensure you and your family receive the available care and coverage that is best suited for your needs is to start researching the available plans and benefits early, as to not make decisions in haste. And while some policies and benefits may appear affordable at first glance, the overall fine print and terminology of the plan will be the deciding factor in how much you spend on coverage. The health insurance industry is still a competitive market, which usually means clever advertising, and appealing price listings will be tactfully displayed to gain your interest and perhaps your business.

I am completely aware that some individuals and families may not have many options, if any at all. This is sometimes the case with employer-based health benefits, where an agency may offer a selection of available plans, a single provider with a high or low plan, or just one option altogether. The entire process can be overwhelming for all of us, and the fear of making an unwise choice should not be a burden held by any of us.

The first step in choosing a health care plan is to evaluate your situation and your anticipated health care needs over a year-long time frame. Consider the past calendar year of visits to primary care providers, urgent care providers, emergency rooms, or any specialty provider. If you do not use the health care system very much, the most basic plan available might be the best option. Even the most basic plans are still going to cover annual physicals, vaccinations, and most preventive screening evaluations. For individuals or families that have specialized needs as well as routine health care use, the options need to be more carefully considered. While a lower co-pay and lower deductible may sound appealing at first glance, the overall annual and lifetime maximums also need to be considered, as they play a critical role in your expenses.

Since many of these options yield so many puzzles, I sought out professional advice from a health care broker. Joel Lee is a broker with Health Markets, serving the residents of Englewood and the greater metro area. “Unfortunately a lot of people that go and buy health insurance on their own without a broker’s help, they buy based on some common misconceptions,” he said. “You kind of have to do some math with those choices and not buy just completely emotionally.”

Another significant component is not to get locked in on looking at the deductible, but consider the maximum out-of-pocket amount as a primary deciding factor. “I call it getting tunnel vision on the deductible,” Lee remarked while discussing the common mistakes often made when selecting a plan. He noted that the high cost of a low-deductible premium can wind up costing more on the back end with co-pays and coinsurance.

The table below utilizes the major components of a health care plan for a hospital visit bill of $20,000. The example describes two separate policies, one with a lower monthly premium and another with a lower out-of-pocket maximum cost.

 

Example 1 Example 2

$350 per Month Premium

$20,000- Hospital Bill

$2,500 – Deductible

30% – Coinsurance

$7,900 – Out-of-Pocket Maximum

————————————

Total Visit Cost: $7,750

Annual Premium Cost:  $4,200

 

Total Spent: $11,950

$550 per Month Premium

$20,000 – Hospital Bill

$1,500 – Deductible

20% – Coinsurance

$4,500 – Out-of-Pocket Maximum

————————————

Total Visit Cost: $4,500

Annual Premium Cost: $6,600

 

Total Spent: $11,100

 

While the two examples are similar in overall result for the single incident, the “cheaper” monthly premium would cost another $150 before the annual out of pocket maximum was reached, costing $1,000 more by the end of the year. This creates a prime example of how a calculation of needs is essential to determine. Enter the health care broker. “That’s why I think getting an honest broker’s help is important, not just someone that can only sell one plan,” said Lee. “You’ve got to find someone that can broker all of these choices, and also be certified with Connect for Health: Colorado. You want to have those choices to know you’re getting in the right spot.”

While the thought of hiring a broker may sound like an additional expense while trying to save money, the truth is quite the opposite. Health care brokers are paid by the health care agencies they represent, not by the consumer. So while you may select a health care plan that is perfect for you on the marketplace, you can get a professional option at no cost to you. (The price and premium you pay will not be any different.) Additionally, a well-versed broker may also be able to assist with state- or federally-subsidized assistance, such as the Connect for Health Colorado program. There are likely many families that are unaware they are qualified for assistance and subsidized health care premiums, as the income requirement is within 400% of the national poverty level for household income.

Lee offers his best piece of advice as: “If it’s overwhelming to you (and for most people it is) get a broker’s help.” The added year-long assistance is another benefit; you have an advocate for you and your family, ensuring your bills are correct, and your benefits are being used properly. Lee has also offered to assist any family within the Roxborough area and ROX Lifestyle Magazine reader with the same free consultation and evaluation he offers to his local clients. Even if you have multiple group options from your employer, he is willing to help ensure you make the best decision for your family.

You can find more information and schedule an appointment at www.healthmarkets.com/local-health-insurance-agent/joellee/

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