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    • What to know before choosing health insurance during open enrollment
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    What to know before choosing health insurance during open enrollment

    Harry Posted on

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    For most people, it is open enrollment period for health insurance. Whether you have an employer-based plan, a government-based plan like Medicare, or you’re going through the Marketplace, it’s time to review your coverage and make your choice.

    We talked to health insurance experts about what mistakes people make and how to best choose the plan that’s right for you.

    Don’t re-select the same plan every year

    These plans change from year to year, even if your employer offers the same plans. Do your research before choosing:

    What is the premium? How much will come out of your paycheck each time? This can change wildly every year. The national average by consumer group is around 6%. healthcare.org. Some plans offered to federal employees will increase by 13.5% in 2025. This can be $100 to $200 a month more than your paycheck.

    What is exemption? How much do you have to spend before your insurance starts picking up the bill? Plans may increase deductibles to keep premiums steady or not increase them too much.

    What are co-payments? If you go to urgent care, go to the emergency room, talk to a mental health professional, or get physical therapy, how much will you spend on each doctor visit? What percentage are you expected to pay for labs, x-rays, CT scans, MRIs, procedures and surgeries?

    What is your maximum out-of-pocket expense? This is the amount you are expected to pay before insurance will cover 100% of your health care. However, you should know what is included in the maximum out-of-pocket expense. Are prescriptions aimed at this? Is there a co-pay for doctor’s visits? Otherwise the maximum amount would only cover procedures, lab fees, tests, hospital stays, etc. Is it valid for?

    Who is covered or “in-network”? See each of your doctors, including specialists, your clinics, your preferred hospital, your preferred laboratory, your preferred clinic for x-rays, MRIs, and CT scans. Are they still on your network? Or will you have to pay out-of-network fees? These things may change mid-year as contract negotiations between insurance companies and providers expire and are renewed, but your providers may know something is coming or whether they will no longer use a particular insurance plan. Also remember, just because your provider says they take Blue Cross Blue Shield doesn’t mean they’ll accept every plan. Check with your provider about your specific plan. You can also look at the insurance website.

    Which prescriptions are covered? Review each prescription you receive and find out if it is on the insurance company’s formulary table and what the co-pay will be. Sometimes insurance companies will choose cheaper medications for a particular condition, but you may need to request an override if that medication doesn’t work for you. If your insurance discounts a particular drug, you can also check the following sites: GoodRx to see where you can find the medicine cheaper.

    What else is covered? Don’t forget any add-ons you might get, like gym memberships, behavioral health services, or blood pressure monitoring. Are these still provided?

    What other questions should you ask?

    What health needs do you foresee this year? “You’re speculating no matter what,” said Louise Norris, health policy analyst for the consumer group. MedicareResources.org. “None of us really know how much health care we will need.”

    John Hatton, senior vice president of the National Association of Active and Retired Federal Employees, said health insurance is about how comfortable you are with the risks.

    If you’re relatively healthy and don’t have a lot of health-related expenses, you can look at a high-deductible plan that will cover you in case of emergencies but won’t cover most day-to-day expenses. However, you should not give up on enrolling in healthcare in this scenario. “This is a really bad idea,” he said. “Skipping insurance is death. You risk bankruptcy, you risk not getting care.”

    If you know you will be using multiple services or have an upcoming surgery, make your plan based on what you will use. This could mean a lower deductible but higher priced premiums.

    Is your current plan still valid or will you be redirected to a plan you didn’t choose? Employer plans, Medicare Advantage plans, and Marketplace plans change every year. You’ll usually be automatically enrolled in a similar plan, but don’t count on it. It may also not have the coverage that would make your previous plan work for you. Instead of passive renewal, “we want people to actively renew. They’re choosing this plan, and that’s no accident,” says Rudy Ybarra of Marketplace insurance provider Sendero Health Plans. People are more likely to use coverage when they are actively enrolled, Ybarra said.

    Does the plan you want cover everything you need? Are vision, dental, hearing and prescriptions covered under the same plan or do you need separate coverage for them? This is especially true for Medicare and Medicare Advantage and employer plans.

    How will each family member get coverage? For families where two adults work, compare what is offered in each employer plan and how it will affect each member of the family. Consider both the plan’s costs and out-of-pocket costs for each member. Sometimes there is an advantage to having your spouse and children on one plan and you on another. Sometimes there is an advantage to having everyone covered by the same plan. Sometimes, depending on your income, it may make sense to insure children under Medicaid or CHIP rather than through an employer plan.

    Are you putting off insurance because you don’t think you can afford it? If you’re postponing your knee replacement surgery because your current plan is too expensive, consider getting a plan that has a higher monthly cost for that one year but covers more of the cost of the surgery, which will save you even more expenses. long run Then this will be the year to do everything you’ve been putting off.

    What is the rating of the plan you are considering? Market place and federal plans Medicare and Medicaid They all have a five-star rating system. You can also look at the ratings of these plans to make a more informed choice about which employer-based plan to choose when offered plans from different insurance companies.

    Read more: What are the differences between Medicare and Medicare Advantage as the enrollment deadline approaches?

    If you do not have health insurance through work. What are your options?

    You are not alone.

    A report by the U.S. Census Bureau in September found that Texas had the highest rate of uninsured adults ages 19 to 64. This rate is 21.7% compared to the national rate of 11%.

    If you don’t have an employer-provided plan or can’t afford an employer-provided plan, you have the following options:

    Medicare: People age 65 and older can get coverage through Medicare. To be eligible for next year’s coverage, you must sign up before December 7th.

    Medical help: People who have a very limited income, are disabled, or have children whose parents have a very limited income are eligible for Medicaid. Women who are pregnant or within the first year after giving birth are also eligible for Medicaid. Income determinations depend on your age and the number of people in your family. Call 211 or go to: YourTexasBenefits.gov to apply.

    Child Health Insurance Plan: Children whose parents have incomes too high for Medicaid but cannot afford health insurance may qualify for CHIP. Call 211 or visit YourTexasBenefits.gov to apply.

    Medical Access Plan: In Travis County, anyone earning 200% of the federal poverty line, which is $2,510 a month for an individual and $5,200 a month for a family of four, can apply for Central Health’s Medical Access Program, or MAP Basic program. You don’t need to be documented to get a MAP, but you do need to live in Travis County. You can fill out the application form online. CentralHealth.net or call 512-978-8130. Central Health is Travis County’s hospital district and uses funds from property taxes to provide health care.

    Market place: healthcare.gov It offers a variety of plans for people who do not qualify for a federal program such as Medicare, Medicaid, or the Children’s Health Insurance Program and do not have a health plan through their employer, or They do not have a health plan through their employer that meets a certain level of quality or affordability. You can also use the Marketplace if your employer only offers affordable coverage for the employee but not for the rest of the family. The rest of the family may be covered by the Marketplace plan.

    The marketplace is also accessible to people with DACA status, but not to undocumented people.

    This is ideal for people who are self-employed or work multiple jobs who are not full-time or who retire early but are too young for Medicare, Norris said. There is no cap on income in 2025, but there is a coverage gap at the lower end because Texas has not expanded Medicaid.

    Almost 93% of Marketplace enrollees receive some subsidy to reduce the cost of the plan. There are extra subsidies until 2025. It depends on your age, zip code, family size and income. You can find the subsidy calculator at: Health Insurance.org at the same time healthcare.gov.

    “Many people don’t realize that coverage on the Marketplace is so affordable,” Norris said. Some people will pay $0 in monthly premiums. Others may pay $10 or $20. “At least you will have access to care,” Norris said. A hospital has to care for you in the emergency room, but it doesn’t have to pay for any additional treatment you may need. “You definitely don’t want to put yourself in a situation where you’re going to be turned away from treatment.”

    Although registration is open until January 15, you must register before December 15 to be covered by January 1.

    “Get these records early,” Ybarra said. After Thanksgiving, Sendero and other providers will be heavily congested, making it difficult to answer questions.

    Who can help me get health care through these programs?

    local nonprofit organization Foundation Societies It has health navigators specifically helpful to Marketplace. There are currently over a hundred options in Travis County. “If you are feeling overwhelmed, find local health navigators and facilitators available,” Norris said. “That’s the first thing.”

    Director Erika Leos Successful Programs For Foundation Communities, he explains, navigators help people predict their health needs for the coming year, including doctors they want to see, medications they can take, procedures they know they need to have, and match them with the plan that’s best for them. they get the subsidies they need for the plan. They can also help determine whether another program, such as MAP or Medicaid, would be a better fit. To get started, make an appointment at: ProsperHealthCoverage.org or call 512-381-4520.

    You can also go directly to an insurance provider to ask for help understanding and choosing the right program for you. Sendero Health Plans It is a local Marketplace plan provider covering eight counties in Central Texas and is affiliated with Central Health. There is a helpline at 844-800-4693 or you can go to the website. SenderoHealth.com.

    Type Clinic, St. Through a $250,000 grant from David’s Foundation, patients living with HIV or taking pre-exposure prophylaxis medications, also known as PreP, will also be able to connect their patients to the Marketplace and help cover monthly premiums or drug costs. You can call 833-937-5463 or go to: KindClinic.org to start the process.

    Health Alliance for Austin Musicians: HAAM helps musicians pay their insurance premiums through their Sendero Health Plan. MyHaam.org.

    Harry
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