What Health Insurance Questions Should I Ask When Choosing a Plan?
Just the Essentials...
- Your plan’s network determines which doctors you can see and where you can receive medical care. Most insurance plans do not offer international coverage.
- Plans are required to cover ten essential benefits, but added coverage like dental and vision care for adults is not required under the Affordable Care Act (ACA).
- Policies are rated on a five-star scale, with five-star plans having the best coverage and customer service. However, a star rating does not necessarily indicate that a plan is right for you.
- Your plan’s cost is directly related to the amount of out-of-pocket expenses you are willing to take on: higher premiums mean lower deductibles and vice versa.
- The ACA has streamlined claim disputes: however, it’s best to review your policy to avoid a claim dispute in the first place.
So, what health insurance questions should I ask?
Whether you’re buying insurance on the Marketplace or through your employer, there are a few health insurance questions you should always ask. Understanding what type of plan you’re applying for will help you determine the cost of your plan, your deductible, and your coverage limits. Let’s take a look at some important health insurance questions below.
What kind of plan is being offered?
There are several types of insurance plans that can be offered through your employer or the Marketplace, but it isn’t always clear what those plans mean. HMO? PPO? What’s the difference?
While, in the past, there were a wide variety of plans that offered different benefits and types of coverage, the Affordable Care Act has led to standardization in what is considered a qualified health plan.
These plans refer to the size of the plan’s network: the various providers and pharmacies that your insurance plan has made deals with for lower prices. If you buy a plan off of the Healthcare.gov Marketplace or through a marketplace run by your state, that plan is likely to be a managed care plan, meaning that your plan will refer you to a specific physician, and you will be required to stay in your plan’s network.
On paper, there are four types of plans: Exclusive Provider Organizations (EPO), Health Maintenance Organizations (HMO), Point of Service Plans (POS), and Preferred Provider Organizations (PPO). In practice, however, you should primarily know about two:
- Exclusive Plans (EPO, HMO): These plans limit you to in-network providers only, except in an emergency. They will not cover out-of-network care.
– HMOs offer more wellness-focused services than EPOs, like in-home checkups and weight management. However, the general coverage is the same.
- Flexible Plans (POS, PPO): These plans allow you to utilize out-of-network care, but you save money by staying in-network.
– A POS requires you to get a referral before seeing a specialist. A PPO will automatically cover specialist coverage without a referral.
Will I be able to see my current doctor?
A network refers to the group of providers that have signed a contract with a given insurer. The insurer agrees to refer their clients to that provider via their web portal or an automatic assignment. The provider gives the insurer and their enrollees a discount on services in exchange. These providers are considered to be “in-network.”
However, not all doctors take all types of insurance plans: there are various reasons for this, ranging from exclusivity contracts to simply having never heard of the plan in question. In this case, the provider is considered “out-of-network.”
Your doctor’s website will typically list what insurance plans they accept, and their front desks will be happy to tell you if you ask. Ideally, you want to choose a plan that includes your preferred providers as part of their network.
If your preferred provider is not part of your plan’s network, you can still see them if you have a flexible plan. This, however, is likely to result in higher out-of-pocket costs.
What happens when I am away from home?
Networks are not necessarily limited by geographic location. Here’s an example.
You’re enrolled in a plan offered by Famous Health, which your doctor accepts. Famous Health is a nationwide (and fictional) insurance provider that offers plans across the country.
Most of the year, you live in Kentucky. However, you also rent a winter home in Miami. Because Famous Health is a nationwide insurance provider, you can find a doctor in Miami that is also a part of their network. Your location doesn’t matter in this case. In addition, if you have a flexible plan, you could see an out-of-network provider and still be covered.
However, some plans, typically exclusive ones like HMOs, have a service area. In this case, you can only receive non-emergency care in a specific geographic region, which can vary in size and scope. Some plans cover vast areas, like the entire southern United States. Others are limited to smaller areas, like individual states.
Regardless of your plan, all qualified health plans must cover you in an emergency. People don’t have the luxury of telling their ambulance driver to go to an in-network hospital when they’re in critical condition, so it is illegal for insurers to reject coverage on that basis.
What if I am traveling abroad?
Things are different if you leave the country, however. Plans offered through the Marketplace typically only apply to the United States and its territories, and some territories may be excluded. Things are different if you leave the country, however. If you work for an employer that requires you to travel overseas, they may provide international coverage as a benefit. Otherwise, you have a few options.
The first is to purchase travel insurance: this is temporary coverage that lasts the length of your trip. Some services offer other benefits, like evacuation in a non-medical emergency (such as a natural disaster or terror attack), legal services in the event of detainment, or lost luggage recovery. These plans can cover your healthcare expenses at local facilities, and more expensive plans can even provide for medical evacuation in the event of an emergency. These plans are usually your best bet if you’ll only be abroad for a short period.
Other plans offer longer-lasting, more comprehensive coverage. These function much like typical insurance, except the network includes providers overseas. These are great if you live abroad for more than a month at a time.
It’s important to note that travel and international insurance plans are not under the jurisdiction of the ACA. Therefore, they do not necessarily offer the same coverage as a Marketplace plan, and they can choose to reject you based on a pre-existing condition, while most typical health insurance plans cannot.
What does the plan cover?
To be qualified under the ACA, a healthcare plan has to meet the minimum criteria.
First, it cannot reject you based on a pre-existing condition, nor can it charge you higher premiums or cost-sharing fees due to your health. Beyond that, all plans have to cover the ten essential benefits:
- Outpatient care.
- Emergency services
- Maternity and newborn care
- Mental Health and substance use disorder services
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services, including chronic disease management
- Pediatric services, including oral and vision.
In addition, marketplace insurers must also cover contraceptive methods and counseling (not including abortions or vasectomies) as well as breastfeeding counseling and equipment. Specific religious organizations are exempt from providing contraceptive care, however.
Certain benefits, like annual doctor’s visits, preventive services, and birth control, are pre-deductible: your insurance will cover them even before you meet your deductible. In particular, preventive services are always offered at no cost.
Plans may offer additional benefits, like vision and dental services for adults or specialized care for specific conditions. These are independent of the essential benefits and will be outlined on the Marketplace when you apply.
How do I know if a plan is a good one?
There is no such thing as a ‘perfect’ healthcare plan: different plans meet different needs, after all. However, there is a way to gauge the quality of a given plan from the Marketplace.
The government ranks different plans on a five-star scale, with one star being the worst and five being the best. These reviews are conducted by third-party reviewers and strive to be as objective as possible, based on three different metrics:
- How satisfied are members with their care?
- How well does the plan manage its member’s care?
- How well is the plan run from an administrative perspective?
Each metric is given a star ranking, with the plan’s overall rating being based on the average of the three.
Note that a five-star plan might not necessarily be the best option if you need specialized care, a more flexible network, or simply don’t live in a service area. If any of these circumstances sound familiar to you, you might want to go for a lower-ranking plan. Similarly, plans without a star rating aren’t necessarily bad: they might just be too new to have a rating.
How much will the policy cost?
Many important and common health insurance questions center around the issue of cost. The cost of your policy is based on various factors, including the type of plan and any additional benefits it offers. Generally speaking, exclusive plans are cheaper than flexible plans, and plans with additional, non-essential benefits are more expensive than those without.
However, the essential factor to consider when looking at the cost of a plan is how it handles cost-sharing.
No insurance plan, not even Medicare or Medicaid, is entirely free to the beneficiary. While things like tax credits and employee benefits can cover your out-of-pocket costs, you’re still responsible for some portion of your coverage even if you don’t receive a bill each month. That money comes from somewhere, after all.
Most insurance plans have a deductible: the amount of money you must pay before your insurance comes into effect. Not everything falls under your deductible (preventive care is always covered, for instance), but most services are. Beyond that, you also have copays (the portion of a given medical fee you pay when seeing a doctor or receiving medication) and coinsurance (the amount you pay after you meet your deductible but before you reach your out-of-pocket maximum).
In general, your deductible and other shared costs are inversely proportional to your monthly premium: if your premium is higher, you have a lower deductible. If you have a very high deductible, your plan is likely much less expensive.
Healthcare.gov keeps track of these differences using a metal system: bronze plans have high deductibles and low premiums, platinum plans have low deductibles and high premiums, and gold and silver typically sit in the middle. Essentially, you’re choosing to either pay upfront to place the burden of risk onto your insurance company, or you’re choosing to pay less in exchange for taking on more personal risk if you get sick or injured.
Some plans have unique features that might reduce costs further. For instance, Silver plans have cost-sharing reductions that can reduce your deductible and out-of-pocket expenses, and high-deductible plans can qualify you for a Health Savings Account. Consider your options to find the right plan for your situation.
One thing that does not affect cost is star-rating. Depending on various factors, a five-star plan may even be cheaper than a three or four-star competitor. Some plans even receive government benefits for high performance, reducing costs even further.
How are claim disputes handled?
Despite all the good they can do, insurance companies still want to look out for their bottom lines. There may come a time when your insurer refuses a claim, and you’ll need to know your options.
The first and most important thing to note is considering why your claim might be rejected. Healthcare.gov lists a few reasons why this might occur, but your best option is to review your policy and ensure that…
- All services you plan to use are both covered and in-network.
- You fully understand your plan’s prior authorization rules for specialist treatment, as some plans will refuse to cover procedures without authorization.
If you encounter a claim dispute, the ACA has streamlined the appeals process significantly.
Many common claim rejections once associated with health insurance shopping have been reduced or eliminated by the Affordable Care Act, making getting quality insurance easier than ever. Still, knowing what questions to ask while shopping can make the process a lot easier.
Do you still have questions? Contact a licensed agent at (800) 318-9984, or enter your zip code to start comparing plans today!