Choosing the right health plan can be a tough decision at any age, but it’s worth the time and thought you’ll put into it. As you research the plans available, it’s a good opportunity to also take stock of your health and consider any expected — and unexpected — health needs you think you might have in the coming year. To help you think things through, here are some questions to ask yourself during the selection process.
1. What important dates should I mark down?
- If you’re signing up for a Medicare plan or a Medicare Advantage plan, the open enrollment period is October 15 through December 7.
- If you’re purchasing a health insurance plan from the marketplace, open enrollment is November 1 through January 15. For a plan that begins January 1, you must sign up by December 15.
- If you’re on a health insurance plan through your employer, open enrollment could happen at different times; although January 1 is a frequent start date for new policies.
2. Are my expected health needs better served by an HMO or a PPO?
As you look over the different plans, you may need to decide between an HMO and a PPO. Here’s how each works: People who have HMOs choose a primary care physician (PCP) from within the network, and that doctor is the point person in managing their healthcare needs. To see a specialist, a person with an HMO would first need to get a referral from their primary care provider. On the other hand, people with PPOs can make an appointment with any healthcare provider without a referral from their PCP. They can also go to providers and facilities outside of their network, but they’ll likely pay more. So, while HMOs tend to cost less, PPOs tend to offer more flexibility and choice.
3. What costs should I consider when choosing a healthcare plan?
There are a number of considerations to compare when deciding among different plans, whether you’re deciding between a plan from the Marketplace or Medicare Advantage, and cost is always an important factor. Some of the costs to consider include:
- Your premium. This is the amount you pay monthly for your health insurance. For some people who have an insurance plan through their employer, the employer may pay a portion of the premium.
- Your copay. This is a set fee you pay for a healthcare service, such as a visit to a doctor or hospital, or for a prescribed medication.
- Your coinsurance. This is the portion of the cost for healthcare that you will pay after you’ve met your deductible. For example, if you’ve met your deductible and your coinsurance is 20% and you receive a bill for $100, you’ll pay $20 and your insurance will pay the rest.
- Your deductible. This is the amount you pay for eligible health services in a year before your insurance policy begins to share costs. If your deductible is $1,500, for example, you’ll pay for eligible costs for up to $1,500 before your policy helps pay for covered services.
4. Are my doctors in the plan’s network?
When a doctor is “in network,” it means that they have a contract through the health insurance plan to provide care to members at a negotiated rate. So the cost for using in-network providers is generally lower than those who are out-of-network. Before selecting a plan for yourself and your family, it’s important to check and see if your preferred healthcare providers are in-network.
5. Will my medications be covered?
To make sure that any of the medicines you expect to take will be included in your coverage, check the plan’s formulary, which is the list of drugs the plan will cover (with Medicare this is called Part D).
6. Will I be able to sign up for coverage outside of open enrollment?
For marketplace health insurance and employer-sponsored plans, there are a few life changes, known as “qualifying events,” that will enable you to sign up for coverage outside of open enrollment. Those include:
- Losing health coverage
- Moving
- Getting married
- Having a baby or adopting a child
- Household income that falls below a certain amount
With Medicare, eligibility starts three months before a person turns 65 and ends three months after turning 65. In addition, people on Medicare Advantage Plans who want to switch to a different Medicare Advantage Plan (with or without drug coverage), or switch to original Medicare or join/switch drug plans if on original Medicare, can do so between January 1 and March 31 or within the first three months you get Medicare. (Read more on that here).
On the other hand, many people will stay on their plan for the entire calendar year. That’s why it’s so important to put time and thought into comparing plans, reading the details on each and choosing the one that makes the most sense for you and your health needs.
