Is your health insurance working for you and your family?
It’s worth spending some time to review your health insurance plan, especially as we approach the end of the calendar year. Many insurance plans have open enrollment periods coming up – that’s the time of year when you can change plans or enroll in a new plan.
Sounds great – but do you have the information you need to make an informed decision about what plan is best for you? When it comes to health insurance, that can be easier said than done. That’s because health insurance is confusing! It is also constantly changing – for example, there are a number of changes in Medicare and Medicaid for 2023.
“Even for those of us whose jobs involve dealing with health insurance on a daily basis, it can be overwhelming and frustrating,” says Dr. Raymond Blair, a family medicine physician in Ennis. “It’s not something that is intuitive to understand, but by knowing some of the common terms associated with insurance, the general types of options that are available and staying current on major changes to different plans, you can have the basic information you need to make good decisions about health insurance.”
A Health Insurance Glossary
The world of health insurance has its own lingo that can be confusing. Here’s a look at some of the common terms and abbreviations you will hear when dealing with health insurance:
- Premium: The amount you pay each month to maintain your health insurance coverage.
- Deductible: The sum you pay out-of-pocket before your insurance company begins to pay your claims. It is generally a fixed dollar amount each year.
- Co-pay: A fixed amount you are responsible for paying for when you visit a health care provider or receive a covered service or product. There are co-pays for visiting a doctor, a specialist, getting an x-ray, having lab work done, filling a prescription, getting hearing aids, using an ambulance and going to an urgent care clinic or emergency room.
- Co-insurance: Similar to a co-pay, except you pay a percentage of the total cost.
- Network: Insurance plans have a group of health care providers they refer to as a “network.” These are providers, such as physicians, hospitals and labs, with which the insurer has a contract that stipulates what the provider will be paid by the insurance company. The bottom line for the patient is that it’s cheaper to see a doctor or go to a hospital that is in-network. Sometimes, however, it is not always practical.
- Out-of-network: This refers to providers who are not in your insurer’s plan. You may pay more to see providers who are out-of-network. Some patients will choose to see a provider out-of-network if they believe that’s the best health care available for their situation. In other instances, such as a medical emergency, it may not be practical to get to an in-network provider in a timely manner.
- Health Maintenance Organization (HMO): HMOs are insurance plans in which enrollees can only see providers who are part of the HMO’s network. A visit to an out-of-network provider will not be covered, except in cases of medical emergency or if the insurer has agreed in advance that it is a medical necessity.
- Preferred Provider Organization (PPO): A PPO allows enrollees to see out-of-network providers, though usually at a greater out-of-pocket cost. There are also fewer restrictions on seeing specialists without a referral from a primary care provider.
- Exclusive Provider Network (EPO): This plan has some characteristics of both HMOs and PPOs. As with an HMO, there is generally no coverage for out-of-network providers. But like PPOs, EPOs do not require you to first get a referral from a primary care doctor before seeing a specialist.
- COBRA: This program gives people who lose health insurance under certain circumstances – such as changing jobs, divorce and other life events – to continue health coverage for a period of time. The person covered by COBRA will likely pay the full cost of their health insurance – they can be charged up to 102% of the total cost of their health plan.
- Policy: This is a health plan issued by a health insurance company. The policy lists your rights and responsibilities as a policy-holder.
- Evidence of coverage (EOC): This is similar to a policy, except it is issued by HMOs.
- Primary Care Provider (PCP): This is usually a doctor of family medicine, internal medicine or obstetrician/gynecologist. An advanced nurse practitioner or physician assistant may also serve as a PCP. PCP is an important term for insurance purposes; your insurance company will want to make sure you have one and will sometimes require a referral from your PCP before you can see a specialist.
- Explanation of Benefits (EOB): Your insurer will send you an EOB after you’ve used your health insurance. The EOB will explain what the total charges were, how much your insurance covered and what amount, if any, you may still owe to the provider. The EOB is not a bill.
- Prior Authorization: In some cases, your physician may need to obtain prior authorization from your insurer for a medical procedure, screening or prescription drug. In these cases, the procedure or prescription in question may not automatically be covered and your provider must explain to the insurance company why it is medically necessary and why it should be covered.
- Preventative Services: This is a category of health care services that are available to consumers and do not require co-pay or co-insurance; they are fully covered by the insurance plan. This includes services such as flu vaccines, some screening tests and wellness visits.
Health Insurance Options
People obtain health insurance in a variety of ways:
- Your employer: This is the traditional way most non-seniors in America have health insurance. You select a plan offered by your employer and you pay a premium that is deducted from your paycheck, before taxes. Generally, the employer pays a share of the employee’s coverage and in some cases, a share of the employee’s family members’ coverage. Sometimes, a labor union will also provide health coverage in a similar manner.
- The Health Insurance Marketplace: The Marketplace is an option for American citizens under 65 to purchase health insurance. People generally use this option if coverage is not available through their employer. Some plans have low premiums and high deductibles, which could make sense for younger, healthy people who don’t have a lot of medical needs. Other plans are more expensive but cover more, which makes sense the older you get. Some enrollees may qualify for a federal income tax credit when they enroll, depending on income. Visit www.healthcare.gov for more information.
- Medicare: This is the federal health insurance program for American citizens who are 65 and older. People who are approaching age 65 should visit Medicare.gov for enrollment information. Some people are automatically enrolled at 65, while others need to enroll themselves. There are three main components of Medicare:
- Medicare Part A is known as hospital insurance, covering hospital stays and some long-term care needs.
- Medicare Part B is medical insurance, covering physician visits and medical screenings and labs.
- Medicare Part D is a prescription drug insurance program.
Some people choose to delay enrollment in Medicare Parts B and D if they have health insurance through an employer that they prefer to keep while they are still working. However, a late enrollment penalty may apply.
- Medicare Advantage: Also known as Medicare Part C, these are private plans sometimes purchased by seniors to supplement the coverage provided by Medicare. Medicare Advantage plans are offered by private companies but must be approved by Medicare. Those with a Medicare Advantage plan still have Medicare coverage, but they receive their benefits through the plan directly, not traditional Medicare.
The additional benefits provided by Advantage plans may include dental, hearing and vision coverage. Out-of-pocket expenses vary between Medicare Advantage plans, as do the provider networks they offer. For these reasons, it is important to compare Medicare Advantage plans just as you would employer-based plans.
- Veterans Administration: Veterans of the United States Armed Forces may be eligible for health benefits through the VA, depending on a variety of factors, including length of time served, discharge circumstances, income and service-connected disability. VA now offers expanded health benefits for veterans who were exposed to burn pits and other toxic substances, including Agent Orange. For more information, visit VA.gov.
- Tricare: Tricare is health insurance for active-duty military personnel, as well as some military retirees. For more information, visit Tricare.mil.
- Medicaid and CHIP: Medicaid and the Children’s Health Insurance Program (CHIP) primarily serve lower-income families. In Texas, Medicaid eligibility is usually limited to children and women who are pregnant or have recently given birth. CHIP is available for some families who earn too much to qualify for Medicaid. Visit www.healthcare.gov or the Texas Health & Human Services Commission.
There are some additional products available that do not offer the same level of financial security as health insurance. Examples include discount cards and health sharing ministries. While these may offer some value, they should not be considered a replacement for traditional health insurance. Additionally, there are some alternative plans available that may exclude coverage of preexisting conditions or essential health benefits, such as mammograms. Be careful when considering these products – they may not provide the benefits you will need in the future.
What’s New for 2023?
There are several significant changes to be aware of for this year, especially with respect to Medicare and Medicaid.
This year has brought about some positive changes for senior citizens enrolled in Medicare. Most people have their Medicare Part B deductible deducted from their monthly Social Security check. Social Security recipients saw a cost-of-living-adjustment (COLA) of 8.7% this year. In addition, Part B deductibles have declined by $7, the first drop in 10 years.
Medicare Part A deductibles, on the other hand, have increased to $1600 per hospital stay. Part A enrollees who have to pay a premium are also seeing a $7 monthly increase.
One of the biggest changes in Medicare helps patients who are on insulin to treat diabetes. Insulin covered by Medicare is now capped at $35 for a 30-day supply, regardless of whether or not the Part D deductible has been met.
Additionally, adult vaccines recommended by the Centers for Disease Control and Prevention will be free of charge for all Medicare Part D enrollees.
Finally, Medicare is beginning the process of negotiating drug prices with pharmaceutical manufacturers. The federal government recently announced the 10 drugs that will be the first ones subject to price negotiations. These are drugs that are commonly prescribed to treat a range of diseases, including diabetes, cancer, blood clots, arthritis and heart disease. The goal of these negotiations is to reduce the out-of-pocket costs seniors pay for drugs.
The Texas Medicaid program has dropped more than 550,000 people so far this year. This is due to the federal government ending the public health emergency related to COVID-19, which temporarily prohibited states from dropping anyone from Medicaid coverage.
Some people who have lost coverage are no longer eligible. But others who have been dropped may still qualify. People who previously had coverage and may still be eligible should create an account and re-apply at the Your Texas Benefits website. If denied after re-applying, visit HealthCare.Gov to look into additional coverage options.
At the same time, a recent change in state law allows new mothers who are on Medicaid to keep their coverage longer. Expanded postpartum coverage means new mothers keep their health coverage for a full year after giving birth. Previously, coverage ended 60 days after giving birth.
Improved Contraceptive Coverage
Insurance plans in Texas are now required to cover prescribed contraceptives in larger quantities. Effective September 1, 2023, Texas House Bill 916 requires insurers to allow an initial three-month supply of contraceptives and a one-year supply thereafter. The goal of this new law is to decrease the likelihood of missed dosages and to improve convenience for patients.
Key Dates for 2024 Coverage
If you have health insurance through your employer, you should check with your plan to find out when open enrollment is. For government insurance programs, here are some key dates to keep in mind:
Health Insurance Marketplace:
- Open enrollment begins November 1, 2023
- Enroll by December 15 for coverage to begin on January 1, 2024
- Open enrollment ends January 15, 2024
- Open enrollment runs October 15 – December 7, 2023
- During this period, enrollees can make the following changes:
- Switch Medicare health plans (Medicare Parts A & B)
- Switch Medicare prescription drug plans (Medicare Part D)
- Change from a traditional Medicare plan to a Medicare Advantage Plan
- Change from a Medicare Advantage Plan to a traditional Medicare plan
- Open enrollment runs from January 1 – March 31, 2024
- During this time period, people enrolled in Medicare Advantage may:
- Switch to a different Medicare Advantage plan
- Switch to traditional Medicare
- Note: you can only change plans once in this period
Selecting a Health Plan
Whether you have employer-based health insurance, are shopping for insurance in the Health Insurance Marketplace or are choosing a Medicare Advantage or Part D program, you will likely have a few options to choose from.
For example, a HMO may be less expensive than a PPO but may also provide fewer benefits or not allow you as many provider options. On the other hand, if you are relatively young and healthy, a less-expensive plan may be right for you. Your employer probably has Human Resources staff knowledgeable about available benefits – if so, take advantage and make an appointment to get your questions answered.
On the Health Insurance Marketplace, you will find a variety of plans at varying costs: bronze, silver, gold and platinum. You’ll pay the least for bronze and also get the fewest benefits; at the other end of the scale, platinum is the most expensive but provides the most comprehensive overall coverage.
You can also compare additional plans on the Texas Department of Insurance (TDI) website.
When comparing costs on health plans, be sure to consider the following factors:
- Premium: the amount you pay each month to maintain coverage.
- Deductible: the amount you must pay out-of-pocket each year before your health plan begins to cover the cost of medical services.
You may find an inexpensive plan but later discover you must meet a high deductible before you benefit from any coverage from the plan. You may also find that your co-pay for each visit, procedure or prescription is higher than you expected. For some people, these low-premium/high-deductible and co-pay plans work just fine; just make sure you have all the facts before deciding.
An additional tool some employers offer for people who opt to enroll in a high-deductible plan is a health savings account (HSA). This is essentially a medical savings account that people can contribute pre-tax income to and then spend later to cover deductibles and other out-of-pocket costs.
Insurance plans have a group of health care providers they refer to as a “network.” These are providers, such as physicians, hospitals and labs, with which the insurer has a contract that stipulates what the provider will be paid by the insurance company.
Understanding an insurer’s network is critical to evaluating a health insurance plan. No matter what type of plan you select, you will pay higher out-of-pocket costs to see a provider who is not in your plan’s network. Whenever possible, you want to stay within your network to keep costs down and you definitely want to make sure your primary care provider and any specialists you see are in your plan’s network. Health insurance plans usually have a directory of providers on their website. PMGNTX providers are in-network for most major insurance plans in North Texas.
Take Your Time & Ask Questions
As you can tell, there’s a lot to absorb when it comes to health insurance. It can be complex and confusing, so don’t hesitate to ask questions of your employer, your insurer or your doctor. Familiarize yourself with the open enrollment dates and various deadlines associated with the health insurance products relevant to you. The more time you spend understanding your benefits and knowing what your options are, the more comfortable you will be navigating the world of health insurance to get the best health plan for your family.
This article has been reviewed and approved by a panel of Privia Medical Group North Texas physicians.
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