Updated July 27, 2013, 11:28 p.m. ET
Millions of Americans will be shopping for their own health insurance for the first time this fall—but they will need to look closely to be sure they get the coverage that best fits their needs.
On Oct. 1, new government-backed online health-insurance marketplaces are supposed to launch in every state, sparked by the federal health law. Around seven million people are projected to buy plans there for 2014, many helped by federal subsidies, and the number is expected to swell to as many as 25 million in later years. Adding to that, some employers are considering new setups where they give workers a set sum of money to select plans in a similar type of exchange created by private companies.
Bronze or Platinum?
The health law sets many requirements aimed at standardizing plans and making them easier to compare. On the law’s public exchanges, for instance, coverage will be divided into four tiers ranging from the cheapest, “bronze,” covering around 60% of health-care expenses on average, through the priciest, “platinum,” covering 90%. There will also be limited-coverage “catastrophic” plans for people younger than 30. All plans will be expected to include certain mandated benefits such as maternity care and hospital stays, and they can’t cap annual or lifetime payouts.
Still, despite the rules, plans may vary quite a bit—giving consumers important decisions to make. “Take your time to understand the plan” you’re considering before you buy it, says Carrie McLean, director of customer service at eHealth Inc., parent of eHealthInsurance.com.
For starters, people have to pick an insurer, and in many markets, these could include new players that haven’t sold commercial plans before. The nonprofit National Committee for Quality Assurance offers “report cards” about existing health insurers at ncqa.org.
Importantly, consumers will be able to choose how they will pay out of their pockets for care. The plans will cap the out-of-pocket total for the year at $6,350 for an individual plan and $12,700 for family coverage. But a plan’s charges could come in various forms including deductibles, copayments or a percentage of the cost of certain types of services, a setup known as coinsurance.
“You need to look at it and say, ‘Can I come up with it quickly?’ ” since treatments for a serious condition may soon ring up the total out-of-pocket maximum, says Karen Pollitz, a senior fellow at the nonprofit Kaiser Family Foundation. And, she warns, consumers may have to pay out the annual maximum sum twice, if they require care that stretches into more than one plan year.
Another key thing for consumers to examine is what doctors and hospitals are in a plan’s network, says Robert Krughoff, president of Consumers’ Checkbook, a nonprofit that rates health plans and medical providers on quality and cost. Exchange plans are expected to often feature limited choices of health-care providers, and who’s included may vary quite a bit.
To try to figure out if the institutions are the best in the area, consumers can look for quality assessments through resources like the website of the nonprofit Informed Patient Institute, informedpatientinstitute.org; the federal Medicare program’s Hospital Compare at medicare.gov/hospitalcompare; or Mr. Krughoff’s group’s GuideToTopDoctors.org and GuideToHospitals.org.
Some health maintenance organization, or HMO, plans may generally not cover out-of-network services. Plans that are labeled as preferred-provider organizations, or PPOs, may still potentially include large charges for consumers who go to hospitals and doctors outside their networks.
Consumers should also probe whether they could face barriers to accessing certain types of care, experts say. For instance, some plans may require referrals by primary-care providers before a patient sees a specialist, or may have extensive pre-authorization requirements.
Another caution: consumers who require certain prescription drugs should check if their medications are on a plan’s list of covered medicines, and how much they may have to pay to get them, experts say.
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