If you want to close your computer and run away when you hear the word “insurance” you aren’t alone. Many people find the world of insurance complex, confusing, and frustrating, and there is a good reason for that. Insurance operates under a set of rules and regulations that many of us know very little about. The vocabulary is confusing and the list of terms is never ending. For many people with complex health conditions, navigating insurance is even more complicated and often requires hours on the phone trying to get various procedures, specialists, or equipment covered by your plan. The goal of this blog post is to simplify one aspect of insurance: enrollment.
Enrollment goes beyond just signing up. It includes the work and research done before you elect a plan. Open enrollment is the period of time each year where people can make changes to their insurance coverage by selecting new plans, updating amounts for flexible spending accounts, or adding on additional coverages. A few key dates for open enrollment for 2023:
- Employer sponsored plans host their own open enrollment. You will need to check with your employer to determine when your open enrollment period begins and ends. Many companies offer open enrollment in the fall if the plan benefits restart on January 1.
- If you purchase insurance through the Marketplace (more on what the Marketplace is in a moment) open enrollment runs November 1, 2022 through January 15, 2023. If you want your coverage to start on January 1, 2023 you need to enroll by December 15, 2022. If you enroll between December 15, 2022 and January 15, 2023 your coverage will begin on February 1, 2023.
- Medicare open enrollment is on its own schedule and it begins October 15, 2022 and runs through December 7, 2022. If you enroll during this time your plan will start on January 1, 2023.
If you are reading this outside of open enrollment periods and you are needing to make a change to your insurance, you may be able to do that now if you have had a qualifying event. This is called special enrollment. Events that allow you to use a special enrollment period include:
- Having a baby
- Change in marital status
- Change in citizenship status
- Losing your job
- Turning 26 and losing your previous coverage
- Change in your income level that impacts your eligibility for tax credits related to insurance costs
Now more on the marketplace…. According to Healthcare.gov the marketplace is “shopping and enrollment service for medical insurance created by the Affordable Care Act in 2010”. The marketplace allows consumers to purchase health insurance plans to meet their individual needs. The Marketplace offers plans that are paid for by the individual.
The Marketplace is an online platform where you can shop for and purchase coverage. You can compare plans and determine which options are right for you. To use the marketplace you must be a United States citizen or national, not incarcerated, live in the United States, and not be covered under Medicare. Some states operate their own marketplace. You can find your state’s marketplace information here: Find Local Help.
Medicare and all of its parts are often another source of confusion for consumers. A great resource for understanding all things Medicare is medicare.gov, but I will do my best to break it all down for you. Medicare covers people over the age of 65, certain people with disabilities, and people with end-stage renal failure. Medicare is not on the Marketplace and you cannot use the Marketplace to purchase supplemental plans if you have Medicare. There are several parts of Medicare and each part provides different coverage.
Part A- hospital coverage
Part B- doctors and healthcare services, outpatient care, home healthcare, durable medical equipment, and preventative services
Part D- prescription drug
Medicare Advantage plans are known as Part C and provide coverages that are typically found in Parts A and B as well as a prescription drug plan. Medicare Advantage plans may also cover services that are not typically covered by Original Medicare (Parts A and B) such as vision, hearing, or dental services.
If you have Original Medicare you can opt to purchase a Part D plan to cover your prescription costs and you could choose to buy a Medigap plan to help lower the costs you are responsible for under Parts A and B.
You can have Medicare and another insurance plan through an employer or other coverage. One payer will be listed as the primary payer and the other as secondary payer. All costs will run through the primary insurance first and then through the secondary. You will still be responsible for anything that is not covered by the primary and secondary payers as well as your copays or coinsurance. If you have more than one insurance plan you will want to make sure that all your providers and pharmacies have both plans on file so they can submit correctly. Secondary payers will often deny claims if the claim is not submitted to the primary payer prior to their review. If you receive a denial you should make sure that the claim was submitted correctly and to your primary payer first.
All this information is great, but what do you do with it? Now it is time to pick a plan or identify what changes are needed to your current plan. This is where people can get even more overwhelmed. Trying to decipher what each plan has to offer and how the costs stack up can be confusing. Understanding your options and making your best effort to ensure that what your choosing meets your needs is critical.
In my career as a social worker I helped many people of various backgrounds, budgets, and medical needs choose insurance plans. Everyone’s situation is unique and this blog post offers general suggestions. We are not insurance brokers (although I will tell you how to find an insurance broker at the end of this post!) so please take this information as general suggestions and not personalized advice. All that said, here is what I learned through the process:
- Set your budget. Look at your finances and determine how much you can realistically afford to pay each month in a premium. You can buy the best insurance in the world but it isn’t going to do you any good if you can’t afford the premiums each month. This step is especially important if you are purchasing a plan through the Marketplace or looking at Medicare Advantage plans. If you are choosing through your employer, fortunately or unfortunately depending on your point of view, you will likely find yourself with less options. It is also important to consider what the deductible and out-of-pocket maximum is on each plan and whether or not you could realistically pay that cost if you needed to.
- Look at your healthcare needs. Do you go to the doctor a lot? Do you have a long list of medications? Are you seeing several specialists? Are you planning to expand your family in the coming year? All of these questions can help you determine the type of plan that will best suit your needs. If you rarely go to the doctor other than preventative care (which many plans cover at 100%) and you have no medications a higher deductible plan may be a good option as you pay less each month in premiums. If you are in and out of appointments and have an ever changing list of medications, you may want to err on the side of caution and opt for a plan with a wider range of providers and medication coverage.
- Get specific about your coverage needs. If you love your dentist or your doctor or you aren’t willing to switch medications then make sure that your providers and medications are covered. Most health plan websites allow you to search for each of your providers to see if they are in-network or not. Don’t forget to check your preferred hospital if you have one. If you are shopping on the Marketplace many of the websites allow you to put in your medication list one time and then it runs it against the plans you select. This will save you time if you have a list of prescriptions.
Maybe you don’t care about your providers and are more than happy to switch to save a few bucks. That’s fine, too! It’s all about making decisions that support your healthcare needs and financial situation.
- Check out their ratings and reviews. In this day and age we rarely choose a restaurant without looking at the reviews. Why would we choose something as important as health insurance without doing the same? Health insurance plans are given a star rating of 1-5 stars. Five stars is the highest rating. The ratings are based on three factors: member experience, medical care, and plan administration. If a particular plan is new they may not have a star rating, this doesn’t mean it isn’t a good plan. It just means that there isn’t enough data to provide a rating yet. You can look up star ratings here: Health Plan Report Cards. The current ratings are based on 2021 data.
- Check out their website. This tip is all about convenience. If you have narrowed it down to a few great options and the ratings and coverages equally meet your needs, then check out their website. So much of the communication and back and forth happens online. If you find the website to be confusing or lacking in basic information that may be a sign to go in a different direction. Whereas if you find a website that has a robust member information section and is user friendly that may save you time and hassle down the road.
One other consideration to make at this time is if you are electing a health savings or flexible spending account. You will want to review your expenditures last year and see if you are contributing an appropriate amount or if you want to adjust your contributions for next year. On that note, don’t forget to use the dollars in your flexible spending account before the end of the year.
Hopefully these tips will help you determine your best options as we head into open enrollment season. If you are purchasing coverage through the Marketplace or are looking at Medicare Advantage plans, the good news is there are insurance brokers who can assist you with the whole process. In my experience, they are like magical insurance unicorns who make this process so much easier. You provide them your budget, your providers and medications, and they run the numbers and pull together options. Most brokers that I have worked with also complete the application for coverage and submit the paperwork on your behalf, but the decision of which plan to choose is yours. Brokers are licensed in your state and are typically required to act in your best interests. If you are interested in finding a broker in your area, you can by looking on your Marketplace website for local brokers. If you live in Minnesota you can find a broker here: Minnesota Brokers and Navigators. Brokers are typically free to you as a consumer and are paid by insurance companies. They must disclose if there is a fee associated with their services.
Let us know how your open enrollment experience goes! Did you find this post helpful? Please share it with a friend or family member. Bonus points if you share it on Instagram and tag @caregivercollaborative.
Bonus tip… Now you’re enrolled in a health plan. Learn about all the benefits available. Can you qualify for gym discounts? Do you have access to virtual or online health care for routine concerns or problems? Are health foods discounted at the grocery store? Is your employer offering discounts on meditation or yoga classes? Health plans and employers are getting creative with additional benefits that go beyond traditional health insurance benefits as a way to attract new members and increase satisfaction. Don’t leave benefits on the table.
