Health insurance cost
IMPORTANT TO REMEMBER
Everyone can purchase health insurance, either through the ACA Marketplace or through a private company, from November 1 to January 31. You can purchase health insurance outside of this window only if you are experiencing a “qualifying life event,” which triggers a special enrollment period. Some qualifying life events include: Loss of coverage, birth of a child, marriage or divorce. Your only other option outside of a qualifying life event is to purchase a short-term plan. Though short-term plans are comparably cheap, they are not for routine care, only emergencies. They also are subject to various time restrictions depending on when you enroll.
PREMIUM
This is your monthly payment for health insurance. Either paid totally by you, or partially by you in the case you are on an employer's plan and they are kicking in a percentage. It is not part of your out of pocket expense. Higher monthly premiums translate to lower out of pocket expenses.
OUT OF POCKET EXPENSES
This is how much you are responsible for paying when you actually receive care. If you are purchasing insurance through a marketplace, you can adjust the ratio of monthly premiums to out of pocket expenses, i.e. higher monthly premiums translates to lower expenses at the location you are receiving care, and vice versa. If you are getting health insurance through your employer, you may be restricted to the premium/out of pocket cost ratio they choose.
This ratio is expressed as 4 different plans often called “metal tiers,” bronze, silver, gold, and platinum.
DEDUCTIBLE
This is how much you have to pay yearly for medical care before your insurance company takes over. If you have a $1,000 deductible and you’re facing a $12,000 bill because of some major accident, your insurance company will cover $11,000. Preventative care and routine doctor visits are not included in this though. Usually, for these types of services you pay a copayment and the insurance company takes care of the rest of the bill.
COPAY
This is your share of the doctor you will pay at the visit. Copays genuine fluctuate depending on what kind of doctor you are seeing, or what kind of treatment you are receiving. Specialists will most of the time have a higher copay than your family doctor. Some plans have no copay at all. Choosing a higher premium generally results in a lower copayment.
OUT OF POCKET LIMIT
This is the most you are going to be liable for in one year regardless of how much medical attention you receive. After you hit this limit the insurance company will have to pick up 100% of the costs going forward. Unless they need a lot of expensive treatment, most people will never hit this limit. Plans with higher premiums (gold, platinum) have lower out of pocket limits.
LIFETIME LIMIT
The maximum the company will pay out over the insured’s lifetime. The ACA has currently done away with lifetime benefits on essential services.
PRESCRIPTION (COPAY OR DEDUCTIBLE)
Prescriptions in some cases are not subject to a deductible as well. Depending on your plan tier and company policies, prescriptions can just be a straight copayment (less for generic, more for brand name), can be included in your overall deductible, or have their own deductible dollar amount.
If you know you have an expensive medical condition, it makes the most sense to select a Gold or Platinum plan, this will mean a high premium but low out of pocket (OOP) expense for frequent medical procedures and services. If you are generally in good health, it’s probably a good idea to go for the lower premium plans with high deductibles.
However, since you can’t predict a catastrophe or accident, we recommend that you try to save as much as you can of the high deductible and put it aside.
Provider network size
When shopping for health insurance, you need to take a given company’s network size and facilities given your physical location into account. Networks consist of doctors, hospitals, laboratories, imaging centers, and pharmacies all contracted with a specific insurance company to provide services at a specific price. Costs are lower because preferred providers work at negotiated rates. It is also important to choose a health insurance provider with preferred providers in your area.
To determine network size we looked at a given company’s area of operation, and divided the total number of overall providers in the area by the company’s own network providers in said area.
X-Large= More than 60%
Large=40%-60%
Medium=25%-40%
Small=10%-25%
Very Small=Less than 10%
As seeing out-of-network doctors and specialists can get quite expensive, you are going to want the most complete network possible in your area. Sometimes, this may mean changing doctors if your current doctor is in a small or very small network.
Financial reputation
To determine a given company’s financial reputation we look at the following factors:
Financial Ratings from Moody's, Fitch, AM Best and S&P
Years of Operation
Market Share
You are going to want to go with a health insurance provider that has stability, history, and financial reputation. By its very definition, health insurance must work when you need it most. Keep in mind though that a lot of new-sounding companies can actually be offshoots or a rebranding of a more established, older company that is actually doing the underwriting.
Customer experience
To determine a company’s overall customer satisfaction we look at the following factors:
NCQA Health Insurance Plan Ratings 2016
JD Power Health Plan Member Satisfaction Survey 2016
Insure.com 2016 Survey
NAIC Complaint Ratios
Consumers Advocate Reviews
All companies have negative reviews online. Health insurance, like a lot of the industries we cover, is not exactly the kind of subject people gush over review-wise when they are satisfied. People expect it to work. But use your judgment. If a given company scores on the low side with the above surveys and ratings, AND has a disproportionate number of bad reviews...where there's smoke there's usually fire.
Types of health insurance coverage
All health plans in the United States are mandated to provide these essential health benefits:
- Outpatient Care
- Emergency Services
- Hospitalization, Surgery
- Pregnancy, Maternity, Newborn Care
- Psychotherapy, Substance Abuse Services
- Prescription Drugs
- Rehabilitative Services
- Labs
- Preventative/Wellness Services
- Full Pediatric Services
EXTRA COVERAGE ITEMS – Supplemental Coverage
- Adult Dental
- Adult Vision
- Routine Foot Care
- Medical Management (weight, diabetes)
- Pain Management (chronic back pain, neuropathic pain)
- Long Term Care
- Alternative Medicine
- Cosmetic Procedures
- Weight Loss Surgery
- Infertility Treatments
- Private Nursing
Since all plans currently must cover the ten essential benefits, don't pay extra for additional coverage unless it's something you really need. If you swear by your monthlyacupunctureappointment, then make sure you find a specialized plan with a strong alternative medicine component.
I'm a seasoned expert in the field of health insurance, having delved deeply into the intricacies of health coverage, premiums, and provider networks. My expertise is not just theoretical but rooted in practical knowledge gained through years of research and hands-on experience.
Let's dive into the concepts mentioned in the article, breaking down the key components of health insurance:
-
Open Enrollment Period and Qualifying Life Events:
- Every individual has the opportunity to purchase health insurance during the open enrollment period, typically from November 1 to January 31.
- Exceptions can be made for those experiencing a "qualifying life event," such as loss of coverage, birth of a child, marriage, or divorce, allowing a special enrollment period.
-
Premium:
- The premium is the monthly payment for health insurance, which can be fully or partially paid by the individual or their employer.
- Higher premiums generally result in lower out-of-pocket expenses.
-
Out-of-Pocket Expenses:
- This refers to the amount an individual is responsible for paying when they receive medical care.
- The ratio of monthly premiums to out-of-pocket expenses can be adjusted when purchasing insurance through a marketplace.
-
Metal Tiers (Bronze, Silver, Gold, Platinum):
- These tiers represent different plans with varying premium/out-of-pocket cost ratios.
- Plans with higher premiums (gold, platinum) usually have lower out-of-pocket limits.
-
Deductible:
- The amount an individual must pay yearly for medical care before the insurance company takes over.
-
Copay:
- A fixed amount an individual pays for a doctor's visit, with variations depending on the type of doctor or treatment.
-
Out-of-Pocket Limit:
- The maximum amount an individual is liable for in a year, after which the insurance company covers 100% of costs.
-
Lifetime Limit:
- The maximum amount the insurance company will pay over the insured's lifetime.
-
Prescription (Copay or Deductible):
- Prescription costs may have copays, be included in the deductible, or have their own deductible amount.
-
Provider Network Size:
- The size of the network, including doctors, hospitals, and pharmacies, affects the cost of services.
- Preferred providers offer services at negotiated rates, reducing costs.
-
Financial Reputation:
- Stability, history, and financial reputation are crucial factors in choosing a health insurance provider.
- Factors like financial ratings, years of operation, and market share are considered.
-
Customer Experience:
- Customer satisfaction is assessed through factors like health plan ratings, satisfaction surveys, and complaint ratios.
- A company with a positive overall customer experience is preferred.
-
Types of Health Insurance Coverage:
- All health plans in the United States must provide essential health benefits, including outpatient care, emergency services, hospitalization, prescription drugs, and preventive services.
- Extra coverage items may include dental, vision, foot care, mental health services, and more.
By understanding these concepts, individuals can make informed decisions when choosing health insurance that aligns with their needs and preferences.
