Which individual health insurance plan is best for you? A Guide to assist consumers with shopping for individual health insurance

Transcription

1 Which individual health insurance plan is best fr yu? A Guide t assist cnsumers with shpping fr individual health insurance Shpping fr 2019

2 Health insurance can be cnfusing, and smetimes it s hard fr cnsumers t chse between all f the plans that are available. There are many ptins. Which is best fr yu? This Guide will ask yu. Yur answers will help yu select the best plan fr yu. First, let s determine yu shuld shp. There are tw ways t buy individual cverage: Thrugh the Marketplace ( r Off the Marketplace (directly frm an insurance cmpany r with the assistance f an agent) Is yur incme belw 400% f the Federal Pverty Level (FPL)? Nt sure? Here is a link t the guidelines fr The guidelines are updated each year. Since yu need t knw the 400% level, multiply the amunt f the pverty level shwn fr yur family size (persns in husehld) by 4. Example: Fr a family f three the 2018 pverty level is $25, % FPL fr that family is $25,100 x 4 r $100,400. Incme belw 400% FPL Apply thrugh the Marketplace. Yu may qualify fr tax credit that will lwer yur mnthly premium. The amunt f reductin t premium depends n yur incme. The Marketplace will determine if yu qualify fr a tax credit and the amunt f the credit. Infrmatin regarding the Marketplace and the plans available thrugh the Marketplace is available n r yu can call Exceptin: If yu are nt lawfully present in the United States yu cannt qualify fr a tax credit and yu cannt buy thrugh the Marketplace. But, yu can buy ff the Marketplace. Incme exceeds 400% FPL Apply Off the Marketplace r thrugh the Marketplace yur chice. Since yur incme is t high t qualify fr a tax credit, yu can buy Off the Marketplace which means yu can deal directly with yur agent r the insurance cmpany. Mre insurance cmpanies ffer plans ff the Marketplace and sme cmpanies that sell thrugh the Marketplace ffer sme plans that are available nly ff the Marketplace, s shpping ff the Marketplace means yu will have mre chices. Infrmatin regarding individual plans available fr sale can be fund at: Frm the Shpping fr Insurance page n this website, yu can find the list f all f the insurance cmpanies, hw t cntact them, and the 2019 rates fr all plans. The calculatr buttn makes it really easy t find the rates fr yur age and yu can srt the plans by premium, by cmpany r by metal level. Nw that yu knw where, let s cnsider t shp. NETWORKS In 2019, all individual plans are either Exclusive Prvider Organizatin (EPO) r Health Maintenance Organizatin (HMO) plans. EPO and HMO plans use netwrks f dctrs, hspitals and ther types f health care prviders. Except fr emergency care, EPO and HMO plans nly cver services and supplies prvided by netwrk prviders. This means yu need t check ut the netwrk!

3 D yu have relatinships with dctrs and ther prviders that are imprtant t yu? If yes, review the netwrks f the plans yu are cnsidering t be sure that yur dctrs and ther prviders participate in the netwrk. This will allw yu t maintain yur relatinship with the dctr r ther prviders. Be careful, a prvider wh says he r she accepts plans frm an insurance cmpany may nt be in the netwrk. Accepts is nt the same as participates. Find ut if yur dctr participates in the netwrk by checking the prvider directries f the plans yu are cnsidering. These can be fund n the carrier s websites and are plan specific s be sure t select the plan name and plan type yu are thinking abut purchasing in rder t get accurate results. Or, call the carrier directly t check n netwrk status. Als, be sure t check that bth yur prvider and the ffice lcatin that yu use are listed in the prvider directry. Sme dctrs practice at multiple lcatins and nt all lcatins may be participating. If n, it is still wise t review the netwrks f the plans yu are cnsidering. Yu ll want t find a dctr! Sme netwrks f prviders may be mre cnvenient fr yu, depending n where yu live and yur transprtatin ptins. Nte: If it is medically necessary fr yu t use a dctr r ther prvider that des nt participate in any plan yu may want t request an in plan exceptin. Refer t the infrmatin later in this Guide. Tiers Sme f the 2019 plans use tiers. This means sme f the netwrk prviders are designated as tier 1 and ther netwrk prviders are designated as tier 2. Althugh bth tier 1 and tier 2 prviders are in the netwrk, yu generally pay less ut-f-pcket fr services when yu use a tier 1 prvider than yu wuld pay if yu use a tier 2 prvider. If yu are lking at a plan that has tiers, hw likely are yu t use prviders in the lwest cst tier? While there are great cst savings assciated with the use f tier 1 prviders, they are nly realized if yu actually use tier 1 prviders. Check the netwrks fr tiers and where yur prviders are in thse tiers! PLAN DESIGN Cst Sharing Cst sharing refers t what yu have t pay when yu use services cvered under the plan. Many individual plans use a cmbinatin f cpayments, deductible and cinsurance. Fr any given service cvered under a plan, yu may be required t pay just a cpayment, r deductible and cpayment, r just deductible, r deductible and cinsurance r just cinsurance. S yu are nt verwhelmed trying t figure ut hw cst sharing wrks fr all services under the plan, let s fcus n yur typical r expected use f services t try and estimate yur ut-f-pcket csts that yu will have t pay in additin t yur mnthly premium. Think f what yur typical year lks like in terms f yur utilizatin f health care.

4 Hw many times d yu g t yur primary care prvider (PCP) fr sick visits? Nw, check ut the cst sharing fr PCP visits under the plan yu are cnsidering. Wellness r preventive visits have n cst sharing. Be sure t lk at the cst sharing fr nnpreventive services. Wuld yu have t pay a cpayment fr each visit? Des the deductible apply? Des cinsurance apply? Try t estimate the ttal cst fr yur anticipated PCP visits under each plan yu are cnsidering. Sme examples might help. If the plan requires a $25 cpay fr each PCP visit, and yu estimate fur PCP visits per year, yu will have t pay $100 ut-f-pcket during the year fr thse PCP visits. If the plan applies a $2,500 deductible fllwed by 20% cinsurance t PCP visits, and yu have nt yet met yur deductible, yu will have t pay the allwed charge (the negtiated rate agreed t between the PCP and the carrier) in full until yu satisfy the deductible. If the allwed charge fr a PCP visit is $100, yu wuld pay $400 fr thse fur PCP visits. Of curse, if the deductible has already been satisfied with ther services befre yu visit the PCP, the 20% cinsurance wuld apply t the PCP visits which means yu wuld be respnsible fr $20 fr each PCP visit. D yu visit specialists? If yes, hw many visits per year? Wuld yu have t pay a cpayment fr each visit? Des the deductible apply? Des cinsurance apply? Fr example, if yu have a medical cnditin that requires yu t see specialists 6 times a year, take a lk at hw the plans cver thse specialist services. Sme examples might help. If ne plan requires a $50 cpay per visit, yu can assume yu will have t spend $300 ut-f-pcket during the year fr thse visits. If anther plan applies a $2,500 deductible and 20% cinsurance t the specialist visits, it is safest t assume that the allwed charges fr thse 6 visits wuld have t be paid by yu ut-f-pcket during the year and wuld be applied twards the deductible. Fr example, if yu have nt yet met yur deductible, yu will have t pay the allwed charge (the negtiated rate agreed t between the specialist and the carrier) in full until yu satisfy the deductible. If the allwed charge fr a specialist visit is $200, yu wuld pay $1200 fr thse six specialist visits. Of curse, if the deductible has already been satisfied with ther services befre yu visit the specialist, the 20% cinsurance wuld apply t the specialist visits which means yu wuld be respnsible fr $40 fr each specialist visit. D yu use ther kinds f prviders such as a physical therapist? If yes, hw ften? Again, check ut the cst sharing that applies t thse types f services. Referencing the examples abve, try t estimate what it wuld cst yu in a typical year. What abut prescriptin drugs? Are yu taking generics r brand name drugs? This ne is harder t estimate because many plans have different csts sharing depending n whether the drug is cnsidered t be preferred r nn-preferred. Yu can call the cmpany r visit the cmpany s website t find ut whether yur drugs are in the lwest cst tier r nt. Sme plans include a limit n hw much yu have t pay fr each prescriptin. If yu take a lt f drugs that kind f feature culd help yu. Nw think abut the cming year. Are yu waiting t schedule surgery, maybe a knee replacement r sme ther type f surgery?

5 If yu are planning a knee replacement next year, yu will want t cnsider hw the plans cver specialist physician and facility charges fr surgery as well as hw they cver charges fr physical therapy, and yur estimated ut-f-pcket csts fr these services. Maximum Out-f-Pcket (MOOP) Gd news! All plans have a MOOP that caps yur ut-f-pcket csts fr the year. Everything yu pay as cpayments, deductible and cinsurance during the year is added tgether. Once the sum f yur cpayments, deductible and cinsurance reaches the MOOP amunt fr the plan yu select, yu d nt have t pay any mre cpayments, deductible r cinsurance fr the rest f the year. In 2019 the per persn MOOP cannt exceed $7,900. When cmparing plans, be sure t take nte f the MOOP amunt fr each plan yu are cnsidering. D yu have a medical cnditin fr which yu expect t use lts f health care services this year? D yu take sme very expensive prescriptin drugs? The MOOP is yur safety net and will cap yur ut-f-pcket csts! TOTAL COST OF COVERAGE When yu buy health insurance the ttal cst f cverage is made up f tw csts: the premium yu pay each mnth PLUS the cst sharing yu pay ut-f-pcket fr the services yu use. Premiums The premium is the fixed amunt yu must pay each mnth fr the plan. Premiums vary frm insurance cmpany t insurance cmpany and frm plan t plan. Premiums are paid whether r nt yu use the services under a plan. Hw much can yu affrd t pay each mnth? If yu are buying thrugh the Marketplace and are eligible fr a tax credit the mnthly premium yu must pay is reduced. If yu are nt eligible fr the tax credit, yu must be able t pay the premium yurself. Cst Sharing Nw g back t yur answers frm the cst sharing sectin. What d yu estimate yur annual csts t be? Will yu reach the MOOP? Math Time! Multiply the mnthly premium by 12 t get the annual premium fr the plan. T that annual premium add yur estimated cst sharing fr the year. If yur estimate f ut-f-pcket csts meets r exceeds the MOOP, simply add the MOOP t the annual premium. Best Value The best value will be the plan with the lwest cst!! But, remember that the plan netwrk is very imprtant, s dn t frget t factr that int yur decisin making with cnsideratin f cst!

6 IN-PLAN EXCEPTION All f the individual plans ffered by the varius cmpanies selling individual cverage in New Jersey in 2019 are netwrk-nly plans. Netwrk-nly plans cver services and supplies prvided by dctrs, facilities and ther prviders that are part f the plan s netwrk. These plans DO NOT cver services and supplies frm ut f netwrk prviders except fr emergency and urgent care. This means peple cvered under the plan will nt be cvered if they vluntarily elect t use the services f a dctr wh is nt in the plan s netwrk. Hwever, if they have an emergency and are taken t an ut f netwrk hspital and treated by an ut f netwrk physician, the emergency services will be cvered. The plans are sld as Health Maintenance Organizatin (HMO) and Exclusive Prvider Organizatin (EPO) plans. Fr the mst part, the plans use netwrks that are New Jersey-nly netwrks. What if yu are currently cvered under a grup plan that lets yu use ut-f-state dctrs and facilities? Or what if yur current plan has ut f netwrk benefits? What if yu are in the midst f treatment with a dctr that is lcated ut-f-state? What are yu suppsed t d? The answer depends n yur medical cnditin(s), yur curse f treatment, yur medical histry and the availability f prviders in the new plan s netwrk If nne f the 2019 plans include yur dctr r facility in the netwrk, and since nne f the plans have ut f netwrk benefits, it may be apprpriate t request that the new cmpany yu select fr 2019 prvide cverage fr yur nging treatment using yur current dctr and facility. Generally, it is apprpriate t request an in-plan exceptin if the medical cnditin cannt be apprpriately treated using prviders that participate in the plan. Maybe the netwrk just des nt have the type f prvider yu need. Or, the netwrk has the type f prvider but the distance is unmanageable r the prvider has n available appintments fr mnths. Persnal preference, regardless f the reasns fr the preference, is nt a gd reasn t expect that an in-plan exceptin will be allwed. Sme examples might help. The first three address situatins that culd warrant an in-plan exceptin. The last tw address situatins where a request fr an in-plan exceptin wuld prbably fail. Example 1: Suppse yu have a medical cnditin fr which there are a limited number f dctrs with training and experience t treat the cnditin. If nne f these dctrs practice in New Jersey r participate in the new plan s netwrk, yu wuld want t request an in-plan exceptin. Example 2: Suppse yu have cmplicated medical cnditins, have used lcal dctrs in the past but they referred yu t ut f state dctrs wh really specialize in treating yur types f cnditins. Yu wuld want t request an in-plan exceptin. Example 3: Suppse yu have breast cancer and will be underging a mastectmy and recnstructive surgery. Yur surgen fr the mastectmy is in the netwrk but the

7 recnstructive surgen yur surgen generally wrks with is nt in the netwrk. Yu wuld want t request an in-plan exceptin. Example 4: Suppse yu have a medical cnditin that can be treated in New Jersey but yu have chsen t use an ut f state dctr and facility because f an excellent reputatin. Or maybe smene yu knw used a certain dctr and had gd utcmes. Yu can certainly request the in-plan exceptin. Hwever, if yur 2019 plan has netwrk dctrs wh have the qualificatins t prvide medically necessary services and wh are accepting new patients it will be difficult t build a case that it is clinically necessary t use an ut f netwrk prvider. Example 5: Suppse yu were diagnsed with a chrnic cnditin such as diabetes several years ag and have t g t an endcrinlgist every six mnths fr checkups. Even thugh yu have a several year histry with the same endcrinlgist, yu wuld prbably nt be successful in btaining an in-plan exceptin t cntinue with the same endcrinlgist since all f the plans have endcrinlgists in the netwrk wh culd perfrm the same semiannual exams and tests fr yur cnditin. A request fr an in-plan exceptin wuld be made t the cmpany yu select fr yur 2019 plan. The request must explain why it is medically necessary t cntinue treating with the dctr and why transitining care t a dctr in the new plan s netwrk wuld nt allw yu t cntinue clinically necessary care. Be sure t address care and treatment anticipated fr It wuld be helpful t ask yur treating dctrs t prvide a clinical justificatin fr cntinued treatment by them. When asking yur dctrs t prvide infrmatin ask them t prepare the same type f justificatin they generally prvide fr a utilizatin review request and t specifically explain why a change in prviders wuld result in a deteriratin f yur health. Yur request will be reviewed by the medical directr at the new cmpany yu select fr the 2019 plan. If the in-plan exceptin is apprved yu will be allwed t cntinue t treat with the dctr and yur cst sharing will be at the netwrk level. In ther wrds, it will be as if yu are using a prvider that is in the netwrk. Please nte that the apprval f the in-plan exceptin may be limited t a certain time perid. If the request is denied yu have a right t appeal the denial. The Appeal and Cmplaint Guide explains the prcess and is available at Questins? If yu have questins yu can get help frm the fllwing: Insurance cmpanies have emplyees wh are ready t help yu understand the plans they ffer. Call and ask questins! D yu have an agent? Talk t him r her. The federal gvernment has a call center set up t help cnsumers understand the Marketplace. The number is New Jersey has a call center with staff that can help yu with questins fr ff the Marketplace fferings. The number is r

8 2019 Carrier List Carrier Name Web Address Mailing Address Telephne AmeriHealth HMO Inc and AmeriHealth Insurance Cmpany Hrizn Blue Crss Blue Shield f NJ and Hrizn HealthCare f NJ Oscar Garden State Insurance Crpratin Oxfrd Health Insurance (NJ) Inc Prspect Plains Rad Bldg M Cranbury, NJ Three Penn Plaza East PP09T Newark, NJ Lafayette St, New Yrk NY Wdland Drive Indianaplis, IN