Buying Health Insurance? Read this First.

Many people are in the process of selecting their health insurance coverage at this time of year. At Better Health Advisors, we recognize that having the right insurance plan is an important part of overall health and wellness. We start with a custom, in-depth assessment of your health and choose a plan that best fits your unique situation. 

We know that buying insurance can be confusing. We’re here to help. Here are the top 10 health insurance questions we get during open enrollment: 

1) Can I switch plans mid year? 

It depends on the type of insurance plan and what the reasons are for the change. If you have a “qualifying life event,” then 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, you may be able to pay for some concierge services using your health savings account.

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

This can be tricky. Doctors often change plans year to year (usually around this time), and this information is not always up to date on their websites. It is best to call the doctor’s office and check with your health insurance plan to be sure.

6) 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 other options for purchasing insurance.  

7) How do the bronze, silver, gold, and platinum metals differ as they apply to insurance choices?

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. 

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

While there are many factors that 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. 

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

Make sure to look at the monthly premiums, deductible, copayments, coinsurance, and out-of-pocket costs. They all add up.

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

In this case, you should either change doctors or change insurance. 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.

Have a question about health insurance, or need help choosing a plan? Call me at (646) 883-9717, or email me at [email protected].