During this time of year, many people are beginning the process of selecting their health insurance coverage. At Better Health Advisors, we understand that having the right insurance plan for you and your family is an important part of overall health and wellness. We also recognize that this process can be confusing and daunting for some, so we will be sharing some tips in a series of three letters.

Each year, the BHA team receives questions about health insurance. As you plan for the 2021 open enrollment season, here are answers to eleven of the most common questions people ask:

1) Can I switch health insurance plans mid-year?

  • This depends on the type of insurance plan and the reasons for the change. If you have a “qualifying life event,” you could be eligible for a special enrollment period.
  • Qualifying life events include:
  • a loss of existing health coverage
  • changes in household structure (such as getting married, divorced, or having a baby)
  • changes in where you live
  • changes in income

2) Can I be denied or charged more based on pre-existing conditions?

  • In short, no. Health insurance companies cannot refuse coverage or charge you higher premiums based on pre-existing conditions.
  • However, you can be charged more based on your age, where you live, and if you use tobacco products.

3) What is the difference between an HMO, EPO, PPO, and POS?

  • HMO (Health Maintenance Organization): Members need referrals from their primary care physician to see a specialist and must stay in-network to receive benefits.
  • EPO (Exclusive Provider Organization): Members also must stay in-network, but in contrast to an HMO, they do not need referrals to see a specialist.
  • PPO (Preferred Provider Organization): Members do not need referrals for specialists, and care is covered both in and out-of-network (but costs can be higher for out-of-network care).
  • POS (Point of Service): Requires a primary care physician to manage your care, and provides different benefits dependent upon if members use in-network or out-of-network care providers.

4) Will my insurance plan cover concierge medicine?

  • Typically, no. However, if you have a health savings account you may be able to use it to pay for some concierge services
  • With concierge medicine, you may pay an annual membership fee upfront, but what other fees do members incur? Find out if your insurance covers your concierge doctor or if you will be responsible for out-of-pocket payments with each visit.

5) Do I still need health insurance if I have a concierge membership?

  • Yes. You may want a high-deductible health insurance plan in case of a hospital stay. Using a health savings account may save you money and offer tax benefits.

6) How do I know if my doctor takes a particular insurance plan?

  • This can be tricky. Doctors often change plans from year to year (usually around this time), so the health insurance information on their website may not be up to date.
  • Call the doctor’s office or your health insurance plan to be sure. Look at the back of your insurance card for helpful phone numbers.

7) What are my options for buying insurance for my small business?

  • Companies with 1 to 50 employees can buy insurance through the Small Business Health Options Program (SHOP) on the health insurance marketplace.
  • If you have an LLC you may have additional options for purchasing insurance.  

8) How do bronze, silver, gold, and platinum insurance plans differ?

  • The sequence goes from bronze to platinum, starting with bronze, where the premiums are low and the out-of-pocket costs are high.
  • As the metals progress to platinum, the premiums increase and the out-of-pocket costs decrease.

9) How do I know which metal level is right for me?

  • While many factors go into this decision, a good rule of thumb is that the more care you expect to use, the higher the metal tier you should consider.

10) What costs should I consider when choosing an insurance plan?

  • Be sure to look at the plan’s monthly premiums, deductible, copayments, coinsurance, and out-of-pocket costs. They all add up.

11) What if my doctor does not participate in the insurance plan that I’m considering?  

  • In this case, you should either change doctors or select a different plan.
  • While it is possible to file an appeal to get the doctor considered as “in-network,” you cannot count on your insurance company to make an exception.

As always, we are here to help you navigate health insurance decisions. Have a question about health insurance, or need help choosing a plan? With our clients, we always start with a custom, in-depth assessment of your clinical needs and financial situation to recommend plans. Please don’t hesitate to reach out to John at john@betterhealthadvisors.com or (646) 883-9717.