Open enrollment II: Tips for Obamacare's second year

I’m a notorious penny-pincher, though I much prefer the term “thrifty.” So I have some counterintuitive advice when it comes to picking a Covered California plan: Cheaper isn’t always better.

I’ll explain why below and provide other advice for this year’s Covered California (and private market) open-enrollment season, which starts Nov. 15 and ends Feb. 15, 2015.

Q: I don’t like my Covered California health plan. Can I switch?

A: Definitely. Whether you’re buying for the first time or switching, try to do it by Dec. 15 so you can start your new plan Jan. 1.

If you like the plan you have, you don’t have to do anything except pay your monthly premium. (Your premium may change for 2015. Look for information in the mail from your insurer.)

But please don’t let inertia get in the way of changing plans if it means better health for you and your pocketbook.

 

DO YOUR “NETWORK” HOMEWORK

Almost a year into Obamacare’s big debut, some Ask Emily readers still tell me they can’t find doctors who accept their Covered California (or private market) plans, or that their long-time doctors aren’t covered by them.

The implications of going out-of-network could be enormous: You could owe thousands of dollars beyond your annual out-of-pocket maximum.

Health plans say they have added doctors and hospitals to their rolls and made provider lists more accurate. But a recent Los Angeles Times analysis found “the state’s largest health insurers are sticking with their often-criticized narrow networks of doctors, and in some cases they are cutting the number of physicians even more.”  

So what’s a consumer to do? Homework. Lots of it.

Are there certain doctors you must have in your network? Find out which, if any, Covered California plans they participate in. But don’t take their word alone for it, and don’t wait until after open enrollment to ask.

“I would try the belt-and-suspenders option of checking with both the doctor and the plan,” says Darrel Ng of Anthem.

I agree. Confirm with multiple sources. It’s not fool-proof, but it minimizes your chances of going out of network and facing sticker-shock.

CHEAPER ISN’T ALWAYS BETTER

Now I’ll explain.

When you choose a Covered California or private-market health plan, you also must select a “metal tier” (bronze, silver, gold or platinum), which determines your level of cost-sharing. Bronze plans have the lowest monthly premiums but the highest out-of-pocket costs for medical services. Platinum plans have the highest monthly premiums, but lower out-of-pocket costs.

Many of you who chose bronze-plans did so for the cheaper monthly premiums. That has worked out great for some, especially if you’re healthy and don’t need frequent medical care.

For others, that may not have been the best choice.

If you get sick – or are sick – you’re more likely to shell out thousands of dollars in cost-sharing before you hit your annual out-of-pocket maximum, which will be $6,250 for an individual bronze plan and $12,500 for a family plan next year.

Consider prescription drugs. If you have a disease such as cancer or rheumatoid arthritis, your insurer may classify your prescription medication as a “specialty drug,” which can cost thousands of dollars. With a bronze plan, your share would be 30 to 40 percent of the cost, compared with 10 percent for a platinum plan.

The same goes for doctor co-pays. A primary care co-pay is $60 for some bronze plans and $20 for platinum plans.

Weighing out-of-pocket costs is especially important if you have a chronic disease. “You need to … look at medication costs or repeated visits for disease management,” says Xavier Morales, executive director of the Latino Coalition for a Healthy California.

The big take-away here is to do the math before choosing a plan, and to tailor your choice to your situation. How much health care do you use and at what cost? Which plan will best help you afford that?

I’m not suggesting platinum plans are right for all of you. Here’s a case in point: Some Covered California customers who make between 138 percent and 250 percent of the federal poverty level will qualify for additional subsidies that will reduce your out-of-pocket costs. But you will only receive this benefit if you choose a silver plan.

GET HELP

Don’t do this alone. Get help, preferably from someone who can walk you through your options in person.

Covered California hasn’t exactly distinguished itself for customer service, given its interminable phone wait times and frequent website breakdowns.

The agency pledges to do better this time around, and has expanded online chat options and customer-service hours, hired more phone reps and aims to better communicate with customers who don’t speak English as their primary language.

But why risk it? There’s personal help available for free. (If someone tries to charge you, don’t pay and report him/her to Covered California.)

Covered California has trained about 6,400 enrollment counselors at clinics, churches and non-profit organizations and certified about 12,000 insurance agents who can enroll you in Covered California plans. (Insurance agents can also help you with private market plans.)

You can search for nearby resources by clicking the “Find help near you” link at www.coveredca.com or calling the customer service number (good luck!) at 800-300-1506.

I receive insurance through my employer, but if I were in your shoes, I’d probably find a certified insurance agent who has had years of experience with health insurance before Obamacare.

“It’s like taxes,” Morales says. “I would recommend you go with someone you trust … Especially if it’s free.”

Learn more about Emily here.

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