Open Enrollment Is Here: Don’t Choose a Health Plan Based on the Premium Alone

Every fall, millions of people are asked to make an important decision: Which health insurance plan should I choose for next year?

Whether you're selecting coverage through an employer, Medicare, the individual marketplace, or another source, it's tempting to compare the monthly premium, deductible, and maybe the copay—and call it a day.

But the least expensive plan on paper isn't necessarily the least expensive plan for you.

A plan with a lower premium may have a smaller provider network, higher out-of-pocket costs, more prior-authorization requirements, different prescription coverage, or limits that matter considerably once you actually need healthcare.

Before you click “Enroll,” take some time to investigate what you're really buying.

1. Are Your Doctors and Clinics Actually In-Network?

Don't assume that because your physician accepts one plan from an insurance company, they accept every plan sold by that company.

Networks can differ by:

Employer • plan type • HMO vs. PPO • Medicare Advantage product • geographic area

Make a list of the healthcare professionals and facilities you don't want to lose:

Primary-care physician • specialists • chiropractor • physical therapist • mental-health provider • hospital/health system • pharmacy • other regularly used clinics

Then verify each one.

And whenever possible, check with both the insurance company and the provider's office.

Don't just ask:

“Do you take Blue Cross?”

Ask:

“Are you in-network with this specific plan?”

The exact plan matters.

2. Look Beyond the Deductible

The deductible is only one part of your potential cost.

Compare:

·         Monthly premium

·         Individual and family deductible

·         Copays

·         Coinsurance

·         Out-of-pocket maximum

·         Prescription costs

·         Specialist costs

·         Emergency-room and hospital costs

·         Out-of-network benefits

A plan with a $1,000 deductible isn't automatically better than one with a $3,000 deductible if the rest of the benefit structure doesn't fit the care you actually use.

Ask yourself:

What would this plan cost me in a bad health year—not just a healthy one?

3. Check the Services You Actually Use

This is one of the most overlooked parts of open enrollment.

If you regularly use:

Chiropractic • physical therapy • occupational therapy • massage therapy when covered • acupuncture • mental-health services • imaging • specialty care

look at those benefits individually.

Don't stop at:

“Chiropractic: Covered.”

Find out:

·         How many visits?

·         Is prior authorization required?

·         Is there a combined visit limit with PT or OT?

·         Is there a copay or coinsurance?

·         Does the deductible apply first?

Are there medical-necessity or authorization requirements after a certain number of visits?

Two plans can both say “chiropractic covered” while providing dramatically different real-world benefits.

4. Medicare Patients: Understand Original Medicare vs. Medicare Advantage

This deserves special attention because the names can be confusing.

A Medicare Advantage plan is not simply Original Medicare with extra benefits. It is a private health plan that provides your Medicare-covered benefits and operates according to the plan's rules.

Depending on the type of Medicare Advantage plan, patients may have to use a defined provider network. Medicare notes that HMO members generally must receive covered care from providers and facilities in the plan's network except in certain circumstances, while PPOs generally permit out-of-network care at a higher cost. Medicare also states that MA members will typically need prior authorization for certain services or supplies.

That doesn't make Medicare Advantage inherently good or bad.

It means you need to know what you're choosing.

Before enrolling in a Medicare Advantage plan, ask:

·         Are all of my current doctors in-network?

·         Is my preferred hospital or health system in-network?

·         What happens if I need care outside the network?

·         Which services require prior authorization?

·         Are there visit limits for services I regularly use?

·         Are my prescriptions on the formulary?

·         What are the copays and coinsurance?

·         What is my maximum annual out-of-pocket exposure?

·         What happens if I travel or spend part of the year in another state?

Medicare itself recommends checking whether your prescriptions are covered and asking your doctors and pharmacies whether they participate in the plan before enrolling.

And increasingly, provider participation itself deserves attention. A provider who accepts Original Medicare does not automatically have to be in-network with every Medicare Advantage plan. Medicare specifically advises MA members to verify whether their provider is in the particular plan's network.

5. Check Every Prescription You Take

Don't assume:

“It has prescription coverage, so I'm good.”

Find the plan's formulary—its list of covered medications—and check your actual medications.

For each one, look at:

·         Is it covered?

·         What tier is it on?

·         What will I actually pay?

·         Is prior authorization required?

·         Is step therapy required?

·         Is there a quantity limit?

·         Is my pharmacy preferred or merely participating?

These distinctions can add up to hundreds or even thousands of dollars over a year.

Medicare drug plans, for example, may use prior authorization, step therapy and quantity limits.

6. Pay Attention to Prior Authorization

A benefit isn't quite as useful if accessing it becomes an obstacle course.

Look for prior-authorization requirements for things such as:

Imaging • procedures • specialty medications • rehabilitation • certain specialist services • durable medical equipment

Prior authorization doesn't necessarily mean a service won't be covered. It means additional approval may be required before the plan will pay.

If you have a chronic condition or know you regularly need a particular type of care, this deserves more weight in your decision than it might for someone who rarely uses healthcare.

7. Don't Ignore the Provider Network

A narrow network can save money—until the provider you need isn't in it.

Consider not only the clinicians you see today, but also where you would want to receive care if something significant happened.

Check:

·         Your preferred hospital

·         Major specialty centers

·         Urgent-care options

·         Mental-health network

·         Pediatric specialists if you have children

·         Out-of-area coverage if you travel

For employer plans, also determine whether the plan is an HMO, PPO, EPO, or another network arrangement and whether there is meaningful out-of-network coverage.

Your Open Enrollment Checklist

Before choosing a plan, print this list—or save it on your phone—and check every box:

☐ My primary-care provider is in-network

☐ My specialists are in-network

☐ My chiropractor/therapists/other regular providers are in-network

☐ My preferred hospital and health system are in-network

☐ My prescriptions are covered

☐ I checked medication tiers and prior-authorization requirements

☐ I understand my deductible

☐ I understand my copays and coinsurance

☐ I know my annual out-of-pocket maximum

☐ I checked the benefits for services I actually use

☐ I checked annual or combined visit limits

☐ I know which services require prior authorization

☐ I understand my out-of-network benefits

☐ I checked urgent and emergency-care coverage

☐ I checked coverage when traveling/out of state

☐ I compared the total potential annual cost, not just the premium

One more box:

☐ I saved a copy of the Summary of Benefits/Coverage and plan documents I relied upon when making my decision.

That last one is worth doing. Benefits and phone conversations can become surprisingly difficult to reconstruct months later.

What If Your Insurance Company Denies Something?

Patients have rights.

A denial is not necessarily the end of the conversation. Health plans have internal appeal processes, and depending on the type of insurance you have, external review or government assistance may also be available.

For Minnesota patients, the correct agency depends on the type of plan. The Minnesota Department of Commerce regulates many individual and fully insured employer plans; the Minnesota Department of Health handles HMO matters; self-funded private-employer plans generally fall under federal ERISA oversight through the U.S. Department of Labor; Medicare handles Medicare and Medicare Advantage complaints and appeals; and Minnesota DHS handles Medical Assistance and MinnesotaCare.

Helpful patient advocacy resources

·         Medicare: Medicare.gov — compare Medicare options, providers and drug coverage. Medicare can also be reached at 1-800-MEDICARE (1-800-633-4227).

·         Minnesota Department of Commerce: Health Insurance Consumer Protections — assistance with many individual and fully insured employer plans, complaints and external review. Consumer Services: 651-539-1600 or 800-657-3602.

·         Minnesota Department of Health: HMO Appeals & Complaints — assistance for Minnesota HMO enrollees with complaints and external appeals.

·         Minnesota DHS: Resolving Problems With Your Health Plan — information for Medical Assistance and MinnesotaCare members regarding grievances and appeals.

·         U.S. Department of Labor: For many self-funded employer-sponsored plans, the Employee Benefits Security Administration can assist with benefit questions and complaints at 866-444-3272. Minnesota Commerce specifically directs consumers with these plans to the U.S. Department of Labor.

·         And Medicare beneficiaries can also use their local State Health Insurance Assistance Program (SHIP) for free, personalized Medicare counseling that is not affiliated with an insurance company or health plan. Medicare specifically recommends SHIP as a source of unbiased assistance.

Our Advice: Don't Be Afraid to Ask Questions

Insurance is complicated—even for those of us who work with it every day.

Before enrolling, call your insurance company. Call your doctors. Call your pharmacy. Ask questions. Write down the representative's name, the date of the call, and any reference number they provide.

And don't be afraid to ask:

“Can you show me where that is stated in my plan documents?”

A few extra phone calls during open enrollment can prevent some very unpleasant surprises after January 1.

The Bottom Line

Don't choose health insurance based on the premium alone.

Choose based on the healthcare you and your family actually use:

Your doctors. Your medications. Your hospitals. Your therapies. Your health conditions. Your budget.

The best insurance plan isn't necessarily the one with the lowest monthly premium or the flashiest extra benefits.

It's the one that provides access to the care you actually need.

Our front desk staff is always available to answer your questions about what networks we participate in or address any other concerns you have. No insurance or chose a plan that doesn't cover the services you want? Ask us about our cash plans and packages that help keep care available AND affordable. Call us any time at 651-232-6830.