Health insurance is one of the most important things we can have in place to protect our health – and our finances. At the same time, health insurance can be extremely confusing, and it may feel overwhelming trying to make sense of it.
The health care providers of Privia Medical Group North Texas want their patients to have accurate and up-to-date information about health insurance options. Fall is a great time to take stock of your current health insurance coverage and consider if any changes are in order. Many (though not all) employer-based insurance plans hold their annual open enrollment period, the time in which you can make changes to your plan, at the end of the calendar year. Additionally, many government health plans also allow for changes this time of year.
Why Health Insurance is Necessary
Health insurance, like all forms of insurance, is intended to protect consumers from unacceptable levels of financial risk.
Those who are relatively healthy may not see the value of insurance if they only need a yearly checkup. But what of the unexpected serious injury that lands them in the hospital or the unexpected diagnosis of a serious illness, like cancer? Those are some of the best reasons to have health insurance – to guard against the unexpected and not be forced into financial ruin when and if those serious events arise.
Just as with homeowners or auto insurance, the premise behind health insurance is one of spreading risk. By having many customers, insurance companies collect premiums from a broad base and then use a portion of those funds to pay policyholders’ claims. For many people, those claims aren’t any more expensive than a routine check-up or physical once a year. However, other medical needs are much more expensive, such as delivering a baby, treatment for cancer or various types of surgery. Commonly used diagnostic and screening tools, such as an MRI or a CT scan, can also be costly.
Health insurance isn’t perfect. It is confusing for patients and even for the doctors who deal with it every day. Some plans can leave patients and doctors footing the bill for legitimate health care costs that should have been covered.
Nonetheless, there have been positive developments in health insurance. The COVID-19 pandemic underscored the importance of telemedicine, allowing patients to see doctors virtually. Now, more of those visits are covered by insurance. Additionally, mental health care is better covered by insurance than it used to be.
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.
- 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 make sense the older you get. Some enrollees may qualify for a federal income tax credit when they enroll, depending on income. For 2022, there are 14 different health insurance companies offering plans in the Texas Marketplace. This number may increase slightly in 2023. 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. 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. 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 – these may offer some value but 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 options such as these – they may not provide you the benefits you will need in the future.
What’s New in Health Insurance?
There are a number of significant changes in various government health insurance programs for 2022-2023 that should be of benefit to the consumer.
For the Health Insurance Marketplace, Congress has passed a law that increases the amount of the subsidies that offset the cost of premiums. Not only will the subsidies be more generous, but more people will also qualify to receive them than before. The Centers for Medicare and Medicaid Services (CMS) predicts this change will save “millions of people an average of $800 a year on health insurance premiums.”
In Medicare Part D, the prescription drug program for seniors, out-of-pocket costs for prescription drugs will be capped at $2,000 per year. In addition, Medicare will now have the ability to negotiate lower drug costs for certain popular medications. CMS projects the monthly Medicare Part D premium to be approximately $31.50 in 2023, a slight decrease from 2022.
Finally, a new federal law creates additional health benefits through the Veterans Administration for veterans who were exposed to burn pits and other sources of toxic substances during their service.
Key Dates for 2023 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, 2022
- Enroll by December 15 for coverage to begin on January 1, 2023
- Open enrollment ends January 15, 2023
- Open enrollment runs October 15 – December 7, 2022
- 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 (Medicare Part C)
- Change from a Medicare Advantage Plan to a traditional Medicare plan
- Open enrollment runs from January 1 – March 31, 2023
- 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 Health Maintenance Organization (HMO) may be less expensive than a Preferred Provider Organization (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 of that 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 any plan, be sure to consider four separate cost factors:
- Premium: the amount you pay each month to maintain coverage.
- Copay: the amount you will pay each time you visit a provider or get a prescription filled.
- Coinsurance: a percentage of the total bill you will pay, after you have met your deductible.
- 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 have to 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 making a decision.
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 – your medical home– 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.
This article contains information sourced from:
Centers for Medicare & Medicaid Services