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Health Insurance in the Summer

/, Lifestyle, Uncategorized/Health Insurance in the Summer

Health insurance isn’t a topic that’s approached during the summer months. With all the traveling and busyness of the season, we tend to put the consideration of health insurance plans off until Open Enrollment in November. However, summer is a perfect time to begin the process of examining your health insurance needs and doing your due-diligence in finding the best suited health plan for you and your family. This topic is one we often help our clients navigate. Here are some of the most common Health Insurance options and some considerations:

Employer-provided health insurance: If you are covered by an employer health insurance plan, chances are that you must select one of the available plans made available to you.  Generally speaking, after the implementation of the Affordable Care Act [ACA], four different “Metal Level” plans were developed to help consumers make an easier assessment of a plan that helps to develop the best strategy for themselves. The 4 metal levels are Platinum, Gold, Silver and Bronze. Platinum offers the richest benefit coverage [at the highest price], while Bronze plans offer the highest of deductibles [at the lowest price per month].

Generally, Platinum Plans offer low or no deductibles.  They are designed to have the consumer pay a low Co-pay (a dollar amount) at the point of services and usually have no further cost-sharing after that. There is usually a fixed amount of aggregated co-pays for which one would be responsible, also known as a Maximum Out-of-Pocket.  After which the insurance company pays 100%. As an example you could pay $15 Co-pay for a Primary Care office visit, a $35 Co-pay for a Specialist Office visit.

Gold Plans are a little different. With these plans you first must pay a Deductible, as with any other type of deductible (such as on your car insurance) where you are responsible to pay a certain amount upfront prior to the insurance company covering any expense incurred. A typical Gold plan could have a $600 Deductible. This means that the first $600 per your plan year would be out of your pocket.  After that $600, you would Cost-share with the insurance company where you pay (as an example) 20% and the insurance company pays 80% of all of the remaining costs for your care up to a certain maximum amount [this is known as coinsurance]. Let’s look at an example, you have a medical expense of $1,000.  The first $600 would be your deductible, for which you would pay all of that amount. From $600-$1,000 [the remaining $400] you would pay 20% or $80 for a total of $680. After that at a specific amount, 100% would be paid for by the insurance company.

Silver plans have Higher deductibles, as an example $1,700, with higher Co-pays at the point of service and a 70/30 % Coinsurance, where the individual pays 30% of all costs up to a higher out-of-pocket maximum.

Finally, are the Bronze plans.  Here a typical Deductible is $5,500 and cost sharing of 50/50% up to $6,550. These plans are nicely suited for the healthy individuals, unlikely to reach their deductible. There could be a significant savings in premium over the year while you would pay the whole cost of a small amount of direct costs for care. The individual could also establish a Health Savings Account [HSA] putting Pre-Taxed money into a specialized savings account (giving a tax reduction) to be used for out-of-pocket costs with Never Taxed dollars. The Health Savings Account plans are among the least utilized taxed favored program of great benefit available.

How do you decide which plan is best? Price is always a variable. If you use medical care a lot, maybe the lower co-pays of a Platinum plan is better suited for you, with a lower maximum out-of-pocket.  If you rarely go to the doctor’s, then maybe paying for one or two office visits out-of-pocket per year would prove more cost effective as such making a Bronze plan more appealing. And, as always, those in the middle are going to need more time reaching the “right choice” for them.

Gathering up your last 12 months of medical and drug costs may be a place to begin.  Try to determine your “typical year” and apply that data to each type of plan. Remember that under the Affordable Care Act, in all health plans in America, Preventive care is covered. That means covered in full are the following: a routine adult exam (different from a diagnostic exam), routine GYN exam, Pap smear, mammography, prostate screening to name a few.  These ACA feature might be enough care for many health individuals.  Working with an insurance specialist might help you find the best plan for you.

Non-employer provided health insurance: If you do not have access to coverage through an employer group, or if the employer does not pay a portion of the premium, you mighy consider going to the New York State Marketplace and secure excellent insurance there. The same options as employer-provided insurance are generally available.  The benefit of the Marketplace is that you might qualify for a monthly tax credit, thus lowering your monthly cost for the insurance coverage itself.  This works like a ‘subsidy’ through the ACA. If your household income is below 400% of the Federal Poverty Level you might be eligible for a reduction in your monthly premium.  That equates to $48,200 for individuals, $64,900 for couples and $98,400 for a family of four. [Qualification is determined by the New York State of Health Marketplace. These limits are provided as guideline only and other variables could apply to determine eligibility]

Regardless of how you reach your health insurance decisions, don’t leave such choices until the last minute. Call us or a different health insurance expert to help you find what is best for you. Let’s Talk!