Help is on the way for consumers flummoxed by health insurance forms, but they’ll need to be patient.
The health care overhaul, which aims to provide coverage for millions of uninsured, requires private health plans to offer a user-friendly coverage summary. This form must explain key terms and cost details. The goal is to make it easier for people shopping for individual or employer-sponsored group coverage to compare policies and understand how different parts of the coverage will affect them.
The Health and Human Services Department recently announced what will be required in these summary forms, but insurers won’t have to comply with the requirement until September.
In the meantime, here are some key points to keep in mind when picking a new plan.
1. Focus on what you need
Anyone shopping for insurance should consider how they used their health coverage in the past year and how they plan to use it in the year ahead before looking at options. That will help determine which plan fits best. For example, think about whether you are planning any surgeries or physical therapy.
Note any regular medications that will need coverage. Make a list, if necessary, of favorite doctors or specialists. If you see a doctor frequently, a plan that limits visits may not be smart. But that coverage could be an option for a young person who rarely gets sick.
2. Know your options
Before diving deep into the guts of any one plan, understand the range of possibilities. That may be a simple task for someone who’s relying on their employer. Companies often give their workers only a few options, if any, to choose from, and human resources may be able to help.
The situation is more complex for individuals buying insurance on their own. Shoppers may find dozens of options depending on variables, such as their age, where they live and their medical history. A website managed by Health and Human Services — www.healthcare.gov — can help identify options.
Licensed insurance brokers also can help find a suitable policy, especially if someone has a pre-existing condition. A broker may know which insurers will reject certain conditions.
3. Brush up on coverage terms
Current benefits summaries come loaded with terms the average person may not know or perhaps recognizes but doesn’t understand. One of the most important: the annual out-of-pocket maximum. This basically tells consumers how much they may have to pay out of their own pocket in a given year.
“That’s your financial exposure,” said Keith Mendonsa of the online insurance broker eHealthInsurance.com. He recommends that shoppers ask themselves whether they could meet that total if something bad were to happen.
Premiums indicate the price policyholders will pay for the coverage, but don’t get too locked into that number. If you see a small monthly premium, understand why it’s low. Generally, coverage with a low premium comes with a higher deductible.
Understand how deductibles work in a plan. These are the annual amounts a patient pays out of pocket for care before most insurance coverage starts. Coverage may involve different deductibles for hospital services, prescriptions, and care delivered outside the insurer’s network of providers.
4. Watch out for exclusions
People become so focused on what a plan covers that they forget to check on what it does not cover, said Dr. Wendy Shanahan-Richards, a medical director for the insurer Aetna Inc.
A woman of child-bearing age should never assume that an individual health insurance plan covers pregnancy or maternity care.
Some diagnostic tests or surgeries such as bariatric procedures may be excluded. Cosmetic procedures also frequently are excluded, along with fertility treatments.
People shopping on the individual market who historically have had coverage through their employer may not realize that dental and vision insurance do not come with health coverage.
A specific doctor, hospital or lab may not be excluded from coverage but may fall outside an insurer’s care provider network. That means you’ll have to pay more, which could lead to big bills. Patients with a regular doctor should check on network inclusion before committing to coverage.