Navigating health plan maze to get the best coverage, price

Words to know

• Premium: The cost of your insurance per month. You pay this amount even when you do not use services.

• Deductible: The amount you pay for health costs per year before your insurance begins to pay its share.

• Co-pay: The fixed amount you pay ($15, for example) for some medical services or medicine. This does not count toward deductible.

• Co-insurance: Your share of the costs (20 percent, for example) of certain health care services after paying the deductible.

• Out-of-pocket maximum: The maximum amount you will pay in one year for medical services, not including premium payments.

• Network/in-network: Doctors and other medical staff your insurance will pay for you to see.

Source: Washington Healthplanfinder

Do the research

When it comes to making decisions, consumers devote more time to researching computers and television sets than they do insurance benefits.

Here’s how much time people spend researching before making purchases:

• Home: 40 hours.

• Car: 10 hours.

• Vacation: 5 hours.

• Mortgage: 5 hours.

• Computer: 4 hours.

• Television sets: 2 hours.

• Insurance benefits: < 1 hour.

Sources: Zillow Mortgage Marketplace Survey and Aflac Open Enrollment Survey

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When the state-based insurance exchange opens for business Saturday, Washington residents will have nearly twice as many health plans to choose from as they did in the 2014 exchange.

Ten insurers will sell 82 individual health plans across the state in the 2015 Washington Healthplanfinder exchange. Last year, eight insurers offered 46 plans. In Clark County, six insurers will offer 31 health plans — up from three insurers and 18 plans in the 2014 exchange.

But the growing number of options may lead consumers to ask one question: How do I choose a health plan?

To answer that question, The Columbian sought advice from insurers, insurance brokers and exchange officials.

Know the costs

While the upcoming open enrollment is for people who purchase individual health plans through the exchange, open enrollment periods aren’t exclusive to the exchange. People who purchase plans outside the exchange or have employer-provided plans or Medicare also have annual open enrollment periods.

During open enrollment periods, people can make changes to their insurance coverage for the following year. Because those changes are locked in until the next open enrollment, insurance officials say it’s important to consider any anticipated health care expenses, such as a pregnancy or surgery, when selecting a plan.

“This is a really important decision and people should make sure they understand what type of costs they’ll have over the year to help them decide what type of health plan they should pick,” said Bethany Frey, Washington Healthplanfinder spokeswoman.

With their health needs in mind, consumers need to understand what’s included in a plan and how costs are divided between the insurer and the insured, said Tandy Kooch-Cleaver, vice president of sales and account management for UnitedHealthcare.

Before choosing a plan, consumers should consider their premium amounts (including how much might be paid by employers or offset by tax subsidies), as well as annual deductibles, out-of-pocket costs and co-pays, Kooch-Cleaver said.

But don’t let the monthly sticker price be the only factor considered when selecting a plan, said Carolyn Shelby, an insurance broker at Life Happens Insurance Solutions in Vancouver.

A person who is generally healthy and only sees the doctor once a year for an annual wellness visit may benefit from a lower-premium bronze plan, she said. But someone with multiple health needs may be better served by a silver or gold plan that has a higher premium but lower deductible, Shelby said.

“If people are just looking at price, they can find themselves with a plan they don’t like,” Shelby said. “They could be stuck there for a year.”

In-network providers

Some of the most important things to consider when selecting a plan are not apparent by just looking at a plan’s premium, Shelby said. For example, if the consumer has specific physicians they want to see for medical care, it’s important to make sure those providers are in-network or preferred providers, she said.

If the provider is not a preferred provider, the patient will either have to find a new physician or pay a higher cost to see the provider, Shelby said. And just because a provider accepts a health plan one year, does not mean they will accept it the following year, she added.

“Whenever you see a doctor from now on, you need to ask if they’re still on the list of preferred providers, because that changes rapidly,” she said.

The same goes for specialty services. A surgeon, for example, may be on the preferred list but he or she may use an anesthesiologist who is not, Shelby said. It’s important for the patient to specify their desire to use in-network providers, she said.

“If they’re not on the preferred list, it’s time to cross them off,” Shelby said. “You should be in the network with providers you want.”

Consumers should also research whether plans offer other services they’re interested in using, such as chiropractic, naturopathy and acupuncture, Shelby said. The same goes for dental and vision benefits.

Understanding benefits

Consumers should also have a good understanding of how their benefits will work before using them. The patient should know how much they can expect to pay for a procedure and whether it’s covered by a co-pay or co-insurance, Kooch-Cleaver said.

“A lot of times, people assume things will be taken care of,” Kooch-Cleaver said. Then patients are surprised by bills they receive after the procedure, she said.

Washington Healthplanfinder recently launched a “Know your plan” campaign to help educate consumers about their health insurance options and how to use the plan they’ve selected, Frey said. Resources are available at www.wahbexchange.org/coverage-basics/know-your-plan.

Additional help

Those who still have questions or would like assistance have a few options.

Healthplanfinder navigators can help walk people through the application process on the exchange and help them to find and compare available plans. They provide free, in-person assistance at various locations in the community.

Insurance brokers can give advice, recommend specific plans and enroll people in those plans.

“I really, strongly believe their best choice is to go through a broker,” said Shelby, a broker. “There’s no advantage to not use an agent because they’re no cost. They’re free.”

Brokers are paid a commission by the insurance companies and Medicare for the number of plans they sell.

Insurance brokers can not only help people find the plan that best meets their needs but they are also knowledgeable about the history of insurance companies in the area, what providers are considered in-network and which medications are covered by plans, Shelby said.

Washington Healthplanfinder has a directory of community navigators and insurance brokers on its website, www.wahealthplanfinder.org. The exchange also operates a customer service call center, 855-WAFINDER (855-923-4633).