I am shopping for a private insurance plan in the new health insurance Exchange (also known as “marketplace”). What are the top three things I should consider as I shop for a plan?
Benefits: All health plans must offer a comprehensive package of items and services, known as essential health benefits. These required benefits were designed to make sure you and your family have access to important health care services, such as hospital care, visits to the doctor when you or your child is sick, regular check-ups for your child and you, lab tests and prescription medicines. In addition, all plans must cover dental and vision services for your child.
While all plans must cover the essential health benefits, there can be small differences between health insurance plans. When you compare plans, you’ll see the specific health care benefits each plan offers. If your child has special health care needs, you should pay particular attention to the plans’ coverage of physical, occupational, speech and other therapies, services and devices, such as wheelchairs or hearing aids.
Provider network: You will want to make sure that you have access to all the doctors, specialists and other providers that your child may need. The health plan’s provider network should include a wide variety of pediatric providers, including pediatricians, pediatric specialists (pediatric neurologists, pediatric cardiologists, etc.), occupational, speech and physical therapists, pediatric mental health and substance abuse professionals, and pediatric vision and dental care providers. The plan should also include home care services specifically for children. If you want your child to continue to receive care from his or her pediatrician or other specialists you will need to make sure that they are in the plan’s network.
It is also important that the provider network includes a children’s hospital to ensure that you have access to the specialized and unique care that a children’s hospital provides. Some health plans in some states may not have your children’s hospital in their network, so it is important to check before enrolling in a plan.
In addition, you may also want to see if the plan has any out-of-state providers, including children’s hospitals, in its network. The availability of out-of-state providers in the network is especially important if your child requires specialized care from a children’s hospital in another state or if your child attends school in a different state.
You should also understand how much you will need to pay yourself and how much the plan will pay for care from a provider who is not in the plan’s network (“out-of-network” provider). The plan should allow you to see an out-of-network provider for services that in-network providers do not provide. However, the plan may require you to pay more of the costs for that care or have a different deductible for care from an out-of-network provider. In addition, it is important that you are familiar with how the plan approves out-of-network care, as well as referrals to specialists.
Out-of-pocket costs: When choosing your plan you should consider not only the premium costs (the amount you pay each month for insurance), but the amount of money you might expect to pay out-of-pocket when you or your family uses your health insurance to help pay for medical care.
Plans may charge co-payments for services. Co-payments are the amount of money you must pay each time you visit the doctor. You also may be subject to a deductible, which is the total amount you must pay for medical care before the health plan begins to pay for your care.
The health insurance Exchange in your state must sell four types of insurance plans that differ by how much of your medical expenses they cover and how much you will likely pay in premiums, co-payments and deductibles. The plans offered through your Exchange will be labeled as Bronze, Silver, Gold or Platinum and you should be able to search for a plan by the level of coverage that you want. You can expect the following levels of coverage in these plans:
o Bronze-level plans cover 60 percent of health care costs, while you pay 40 percent
o Silver-level plans cover 70 percent of health care costs, while you pay 30 percent
o Gold-level plans cover 80 percent of health care costs, while you pay 20 percent
o Platinum-level plans cover 90 percent of health care costs, while you pay 10 percent
As you can see, as you move up each level, you can generally expect to pay less for medical expenses overall. Keep in mind that, sometimes, the monthly premiums may be more expensive for higher level plans, but those plans may also have cheaper copayments and smaller deductibles. You will need to determine which level plan makes the most sense given your family’s health care needs.
Some families with low incomes may be able to get help to pay for their health insurance premiums or out-of-pocket costs. The Exchange will help you determine if you and your family are eligible for this financial assistance.
For some children, Medicaid may be a better option. If your child has special health care needs or a chronic condition, there could be coverage options through Medicaid that better meet your child’s needs. You should check with your state Exchange or your state’s Medicaid office to identify your options.