Choosing a health insurance carrier in the healthcare marketplace can be a confusing and difficult process, especially if you don’t get insurance through an employer and have to rely on other means for coverage. The Affordable Care Act (ACA or Obamacare) opened up access to more options for major medical coverage, but more options can mean a bigger headache when it comes to finding the right health plan. How do you choose a carrier? Where should you even start? Let’s take a look at your options and how to pick an insurance company that’s right for you.
What Insurance Do You Need?
You can’t predict your next medical crisis – oh that we could – but you can prepare for it with proper health insurance. Without any coverage at all, you risk paying all medical bills out of your own pocket. A doctor visit for a minor problem might cost $68 while visit requiring more in-depth care could cost around $234. And these are just the office visits. These costs don’t take into account things like lab testing, imaging services and complex surgery, which could bankrupt the average American family without any savings. Even if you’re healthy, accidents can happen that demand visits to a doctor, emergency room or walk-in clinic.
When looking at an insurance carrier, you want to choose one that offers the coverage you need for you and your family. Consider how likely you are to need routine care as well as emergency care. Families with children, for instance, would need greater coverage since kids are more likely to end up in a hospital with broken bones or suffer a gamut of illnesses during fall and winter. Your insurance carrier should provide good coverage for these expected and unexpected medical costs.
Premiums vs. Out-of-Pocket Costs
One important factor to consider is the premium costs you’ll pay compared to out-of-pocket expenses. Private health plans might have lower premiums, but they could have high deductibles and copays to compensate. A policy that has higher out-of-pocket costs could mean that a minor illness will result in you paying most of the charges out of your own pocket with insurance covering very little. Once your deductibles are met, the insurance begins paying, but it could take some time to reach that deductible.
Higher premiums mean lower out-of-pocket costs, so keep this rule in mind when shopping for coverage. Carriers set pricing using their own formulas, and it pays to compare cost details. Read the plan overview and ask questions if you’re not sure how a company structures its pricing. You don’t want to get stuck with a low-cost plan if it doesn’t cover anything you need.
Company Reputation
All companies that sell insurance are strictly regulated by the state in which they’re licensed to sell. Any carrier selling health plans in the Obamacare marketplace for 2019 must meet certain criteria. But not all companies have the same level of service when it comes to handling claims, answering questions or addressing concerns. Accidents and illnesses always seem to happen outside regular business hours. This means you may need to reach someone on a weekend or late at night for questions of coverage and benefits. Make sure the carrier you choose has flexible hours and can be reached when needed.
You also want to verify that claims will be paid on time. Until the insurance company pays, you’re responsible for the bill. If payment runs 30, 60 or 90 days late, you could face collection activity from the healthcare provider. The National Committee for Quality Assurance (NCQA) provides a database of insurance carrier ratings that allows you to research information on the carriers in your state.
Appeals Process
At some point, you may have a claim that gets denied by the insurance company. It could be an emergency room visit that the company determines was not an emergency or a claim that was improperly coded by the doctor. When this happens, you may need to file an appeal with the carrier. Companies handle this process in different ways. Choose a health insurance carrier that makes the appeal process simple and applies the process fairly. One way to be sure claims will be handled as you expect is to read the fine print in your policy to confirm that you have the right coverage. Small loopholes in wording could lead to claim denials that will also be denied on appeal.
Coverage Offered
Once you’ve narrowed down your search to a few different carriers with a strong reputation, you want to determine which companies offer the coverage that best suits your needs. You’ve got more options for health insurance in 2019 than you did last year, thanks to some changes from the Trump administration. Major medical coverage will continue to cover 10 essential health benefits, so know that any ACA-compliant plan available today will include a bevy of benefits that could work for you.
If you don’t need or want, or can’t afford, major medical insurance, new regulations make it easier in most states to buy short term health insurance that lasts up to 364 days and can be renewed for up to 36 months. Consider your health needs carefully before forgoing major medical, though. Short term coverage doesn’t work for everyone, and there are plenty of good reasons to buy traditional health insurance.
When comparing insurance carriers, note the benefits that are important to you – like maternity care or prescription drugs – and see how each company handles those benefits. One may provide more generous coverage, or one might require less cost-sharing on your part. If several carriers offer the same level of coverage for the benefits that matter most to you, then choose the company with a better reputation for these services.
Pre-Existing Conditions
Under Obamacare, health insurance providers are required to cover pre-existing conditions as part of major medical benefits. This means that if a member of your family suffered an illness or injury at any time in their life, treatment for that condition must be covered in major medical plans offered on and off the marketplace in 2019. We should note that short term health insurance doesn’t have to abide by this rule. But as long as what you’re buying is a major medical policy from a legitimate source, your pre-existing condition – whether it’s acne, high blood pressure or cancer – must be covered by law.
Networks
One way that health insurance companies keep premiums low is to require you to use certain doctors, hospitals and healthcare facilities – all part of a “network” of providers. When you’re comparing policies and carriers, pay attention to network limitations. Some plans, like PPOs, allow you to see providers outside the network, but it costs more money and may not be covered as well as in-network care. Other plans, like HMOs, may not cover any out-of-network care. If you have doctors or providers who you see regularly and like, make sure that your insurance carrier covers those providers. If not, you might face higher costs or have to pay the full bill yourself, which renders health insurance useless.
You have lots of options for health insurance, both major medical and short term, and picking a plan from a carrier isn’t always as black-and-white as it could be. But the process doesn’t have to be stressful. With proper planning and careful consideration, you should be able to choose a company that will provide you with the major medical you need at a cost you can afford without any hidden surprises down the road.