How to Shop for Health Insurance {Deadline: December 15!}

Open Enrollment is November 1 – December 15

It’s time to purchase health insurance for 2018. As President Trump’s first year in office winds down, the health insurance market is experiencing astounding turbulence. We answer your top 3 questions to help you cruise through Open Enrollment season without losing your cool.

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1. In Illinois, Blue Cross is the only insurer to offer statewide coverage for 2018. Individuals can purchase on-Exchange or off-Exchange plans between now and December 15th. Plans experienced double-digit premium increases from last year, so review your options carefully instead of just re-enrolling in your current plan.

2. Help is available. If you’re a provider looking to review your insurance contracts or create a financial need policy for underinsured patients, reach out. If you’re a patient who needs help with enrollment, read the full post below and click the link for help.

3. All plans aren’t created equal. A lower monthly premium means a higher deductible. But plans also offer varied provider networks, healthcare benefits, prescription drug formularies, and co-pays. Read the full post below to explore our comparison of two sample plans.

Keep reading to learn more and find answers to your most common questions!

1. How are my options different from last year?

Four insurers are offering individual marketplace plans in Illinois for 2018, and open enrollment period is now underway. The insurers from which individuals enrolling on the marketplace can select are: Celtic, CIGNA, Health Alliance Medical Plans (HAMP), and Health Care Service Corporation (“HCSC,” aka Blue Cross Blue Shield). HCSC is the only insurer offering coverage to the entire state.  Cigna has increased its coverage area from 2017 plans, while Humana left the Illinois marketplace.

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Average rate increases between 2017 and 2018 for the lowest plan in each metal category on the individual market are as follows: Bronze: 20%; Silver: 35%; Gold: 16%. As was the case for 2017, no platinum plans are available on the individual market.

Consumers can also purchase an off-Exchange plan for 2018. While three insurers offer some plans that are available only off-Exchange, all of the on-Exchange individual plans are also available for purchase off-Exchange. While three platinum plans were available off-Exchange in 2017, these won’t be offered in 2018. If you’re interested in purchasing an off-Exchange plan, start by reviewing the options offered by Freedom Life Insurance Company, HAMP, and HSCS. Freedom Life and HCSC offer these plans statewide, while HAMP offers plans in 83 Illinois counties.

2. Can you help?

We help providers evaluate and negotiate their contracts with insurance companies, establish pro bono and financial need policies, and ensure their compliance with the Affordable Care Act. But if you’re a consumer who needs help identifying or securing insurance coverage for 2018, there’s free help available to you. Click here to find someone who can help.  Keep in mind that many organizations offering such assistance are overloaded with Open Enrollment; plan ahead!

3. What should I consider?

(a) Cost
Generally, the higher your monthly premium, the lower your deductible. To illustrate the differences between plans, I’ll discuss two plans available to me in 2018: a bronze PPO and a gold PPO from Blue Cross. While the bronze plan saves me $156.52/month on premiums, my deductible would be $5,500, rather than $750. If I incur any real care costs next year (think: MRI, ER visit, or sports injury), this premium savings wouldn’t be worth it.

Then there’s the differences in the cost of care. The bronze plan requires me to pay a 50% coinsurance for primary care and specialty providers, while the gold plan has nocoinsurance. Under the bronze plan, I also need to pay $40 to see my primary care provider, whereas that drops to $15 under the gold plan. If I need any xrays, imaging, or labs, the bronze plan will require me to pay a 40% coinsurance, but that drops to 20% under the gold plan. If I visit the ER, have surgery, or am hospitalized, I’ll pay a 50% coinsurance with the bronze plan or 30% with the gold plan.

The cost differences continue for prescription drugs. Generics are free under the gold plan but $10 under the bronze plan. On so-called “preferred brand drugs,” the bronze plan has a 30% coinsurance while the gold plan has a 20% coinsurance. Pricier drugs are the same under both plans.

Which will work out better for your pocketbook? Look back at your 2016 and 2017 medical expenses to evaluate what types of services you’re most likely to use.

(b) Provider Network
Is your doctor in-network? This question drives many individuals’ health insurance buying choices, and most providers have updated their 2018 insurance information in advance of the Open Enrollment period. For example, the Chicago-area Northshore University HealthSystem lists their 2018 insurance choices online here. Keep in mind that while a health system or hospital might accept your 2018 insurance, it’s also crucial to confirm that your primary care provider (PCP) plans to participate too.

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(c) Medical Services Coverage
The actual medical services covered by the two Blue Cross plans are nearly identical (Just compare the schedule of benefits for the gold and bronze plans). However, offerings may vary between insurers. For example, a silver Ambetter HMO plan caps rehabilitation services to 60 visits per year, while the Blue Cross plans discussed here impose no such limitations.

Also, remember that HMO plans generally require you to see providers within the HMO network. In contrast, PPO plans reimburse at a higher rate if you stay within the PPO network – but they still provide limited coverage for non-network providers. Thus, if you see an out-of-network physical therapist twice monthly and pay her $150 per visit, that adds up to $3,600 per year. If you have an HMO, 0% of those costs will be covered. If you have a PPO, a portion of those costs will be covered once you meet your out-of-network deductible for the year. Be warned, though: out-of-network deductibles (also sometimes called non-participating provider deductibles) can be really high.

Think critically about your realistic health expectations for next year. Are you planning to finally schedule that long-overdue sinus surgery? Are you having a baby? Do you plan to receive fertility treatments? Do your weekly acupuncture appointments keep your back pain at bay? Health plans vary in their coverage for medical services, so after you consider your likely medical needs for 2018, ensure that the services you need are covered by your chosen plan.

(d) Prescription Drug Coverage
Prescription drug lists (called formularies) aren’t created equal. The availability of generic alternatives, the medical necessity of the medication, and your benefit structure all determine how much you’ll pay for your prescriptions. Before committing to a health insurance plan, check their formulary to ensure they cover your medications. If your drugs are covered, will they require you to switch pharmacies? Will they allow you to use your mail-order service? Ask these questions now, not on January 1 when your plan takes effect.

For Illinois plans, you can view Blue Cross’s formulary here, Ambetter’s formulary here, and Cigna’s formulary here.

Still have questions? Reach out to us.

This blog is made for educational purposes and is not intended to be specific legal advice to any particular person. It does not create an attorney-client relationship between our firm and the reader. It should not be used as a substitute for competent legal advice from a licensed attorney in your jurisdiction.

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about the author

Erin K. Jackson is Jackson LLP’s Managing Partner. She is responsible for all aspects of firm management, is a sought-after speaker for healthcare conferences, and is a published author. She is specifically focused upon the intersection of the patient experience in healthcare with the legal and ethical responsibilities of providers.

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