The end of the calendar year is fast approaching and so are the deadlines for signing up or changing health insurance plans for next year. We’ve previously written about getting to know your health insurance and its financial parameters. Here, we’re going to discuss how to pick the type of insurance that best suits your needs.

The Marketplace on healthcare.gov uses a medal system to rate the benefits you’ll get from insurance. As you go from bronze to platinum, your share of the cost of care decreases and the insurance company contributes more. This is just a rough stratification. It’s important to look the plan’s network setup.

Health insurance plans can be distinguished by the flexibility of the network and whether you need to go through a primary care physician (PCP). Insurance companies control costs by contracting with a group of facilities and providers who are willing discount their prices in exchange for access to the patient pool. This group forms the plan’s network.

There are four main types of insurance plans:

HMO. Generally, a Health Maintenance Organization (HMO) plan has the most restricted network, but the highest level of coverage. You must designate a PCP who acts as a gatekeeper for all of your medical needs. While care inside the HMO when referred by the PCP incurs little to no cost to you, none of the care outside the network is covered. Most HMOs are limited to the geographical area where you live and work.

EPO. An Exclusive Provider Organization (EPO) plan also requires you to remain in a small network, but you don’t need PCP referral to see specialists.

POS. A Point of Service (POS) plan requires you to coordinate care through a PCP, but allows you access to a broader selection of providers, with partial coverage for out-of-network services.

PPO. A Preferred Provider Organization (PPO) plan is more versatile. You don’t need a PCP or referrals and the network usually spans multiple states. PPO is by far the most popular type of health insurance because of its flexibility, but it often comes with a higher premium.

Once you know the network type, check and confirm that your existing providers are in-network. Depending on how you’re covered, you can do this on the plan’s website, through your HR office, or on the Medicare and Marketplace enrollment sites. If most of your providers are local and belong to the same organization, HMO and EPO plans can give you excellent coverage and reduce your out-of-pocket expenses. If you see specialists or travel out of town frequently, you may prefer POS and PPO plans with a nationally recognized company.

Even if you pick a narrow network, there can be exceptions, such as emergency care and coverage for children who goes to school away from home. You can also petition your insurance company to allow you to keep an out-of-network provider for the sake of the continuity of care.

Catastrophic plans

These high deductible plans, with relatively cheap premiums, are available for people under 30 years old or those declaring hardships. The idea is that if you’re young and healthy but would like to have a safety net if you experience an accident or unexpected major illness, that there’s an option for you. However, there are two caveats: you won’t qualify for the premium subsidy, and the plans are still bound by their network. Of note, catastrophic plans provide some preventive care for free and allow you to see your PCP for a few visits per year.

More than ever, ensuring our family’s health and safety is top of mind. Adequate health insurance coverage — reflecting our lifestyles and personal preferences — plays a crucial role in how we plan and execute our health care strategy.

Correction

In our last article, we mentioned that the open-access mandate of the 21st Century Cures Act went into effect on November 2nd.This was the original date designated by the Office of the National Coordinator for Health Information Technology (ONC) at the Department of Health and Human Services which oversees the implementation of the law. However, as pointed out to us by a kind reader, ONC has since issued an interim rule to delay the mandate to April 5th, 2021, because of the COVID pandemic. While some hospitals and EMR developers have been updating their systems to comply with the law and have opened up access, others will likely not be ready until the new deadline, so not all patients are seeing their full medical records yet. We apologize for the error.

Qing Yang and Kevin Parker are a married couple and live in Springfield. Dr. Yang received her medical degree from Yale University School of Medicine and completed residency training at Massachusetts General Hospital. She is an anesthesiologist at HSHS Medical Group. Parker has helped formulate and administer public policy at various city and state governments around the country. He is formerly the group chief information officer for education with the Illinois Department of Innovation and Technology. This column is not intended to substitute for professional medical advice, diagnosis or treatment. The opinions are those of the writers and do not represent the views of their employers.



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