Understanding Health Insurance Options and Open Enrollment
As open enrollment begins on Oct. 1, 2013, many of us need to figure out if the insurance we’re being offered is the best plan given our current medical issues and how we plan to mitigate their effects on our bodies and our lifestyles.
In order to help you out, I’m going to provide a short synopsis of the major types of health insurance currently offered in the United States that I went into detail during the Doctors and Health Insurance Bootcamp. Hopefully this short refresher will solidify a better understanding that will help you to ask the right questions of your employer, individual health insurer or the health exchanges to find the right plan to meet your health insurance needs.
Emphasize coverage for hospitalization or serious illness
Usually do not cover prescription drugs, annual exams or immunizations
Affordable monthly insurance premiums linked with high deductibles
Beneficial for healthy young individuals or individuals who plan to have company provided services in the next six-12 months
High-Deductible Health Plans
- Health insurance plan with lower premiums and higher deductibles
- Plan provides wellness benefits
- Prescription benefits are applied to the deductible but may require the customer to pay out of pocket for prescriptions until the deductible is met
- Eligible for Health Savings Account
- Some plans may have a co-insurance clause
- This type of plan does not have co-pays
Preferred Provider Plans (PPO)
Provide services through in-network doctors
Referrals are not necessary to see specialists
Annual deductibles must be met before insurance company begins covering medical bills
Co-pays are made at the time of service
Some plans may have a co-insurance clause
Eligible for Flexible Savings Account
Some plans may apply prescription benefits to the deductible
Health Management Organizations (HMO)
Reduces cost of providing healthcare by using organizations that utilize techniques to reduce cost
Primary Care Physicians (PCP) provide the majority of care and can provide referrals to specialists within the HMO if needed
Services can only be provided by doctors who participate within the HMO
Services that are provided outside the network are not covered, unless it meets the HMO’s definition of an emergency situation
Combines characteristics of an HMO & PPO
Members select a PCP within the network
Lower medical costs
PCP can make referrals outside the network
In-network visit paperwork is completed & submitted by the providing physician
Out-of-network visits paperwork is completed and submitted by the patient
These types of health insurance will be offered out on the health exchanges. These exchanges will provide consumers who do not have access to medical care through their employer to go out and shop for the best insurance plan that meets their specific needs.
- Insurance companies are not authorized to refuse any individual insurance.
- Price variations will be limited.
- Plans offered on the exchanges will be offered in four tiers with limited out-of-pocket expenses. The tiers will cover between 60-90 percent of bills, in increments of 10 percent.
- Insurance companies are not authorized to refuse to pay claims based upon pre-existing conditions of consumers.
- Lifetime and annual limits for out-of-pocket expenses will be limited at $5,950 for individuals, and $11,900 for families.
The following website has a wealth of information about the state exchanges: Kaiser Foundation: Health Insurance Exchanges. It’s definitely worth your time as a consumer to take some time and bone up on the information here. For those who do not have insurance through your employer, if you have a COSTCO membership, you can buy health insurance through them if you live in any of the following states: Arizona, California, Connecticut, Florida, Georgia, Michigan, Nevada, Pennsylvania, Texas and Virginia. Learn more at COSTCO Insurance Agency, Inc. Additionally, COSTCO’s Health Reform Info Center website is dedicated to changes in healthcare as a result of the Affordable Care Act.
It’s a good idea to identify your health insurance needs before open enrollment begins in October. Take some time to identify what you’re looking for out of your health insurance. US News & World Report has a great heath insurance tip sheet that will help you as you’re considering different types of insurance.
Ask yourself some of the following questions:
- Am I willing to pay a high deductible in exchange for a lower monthly premium?
- Can I cover the high deductible if I’m seriously injured?
- Do I want flexibility and choice when it comes to picking doctors?
Questions to ask the insurance brokers:
- Are prescription drugs costs included in my plan?
- Will I have to pay out-of-pocket expenses for the drugs I’m currently on?
- Do costs of prescription drugs get applied to my deductible?
- With this plan, do I have the choice to see any doctor I choose without a referral?
- Am I required to have a Primary Care Physician?
- Are bio-identical hormones covered under the plan?
- Does this plan have a co-insurance fee after the deductible is met?
- What is the maximum co-insurance annually for in-network and out-of-network providers?
- Does this plan have a co-pay?
- Are chiropractors covered under this plan?
- Are there wellness plans that provide rewards to the insuree, such as lowered premiums, etc. for reducing or eliminating risk for certain medical conditions: eg. cardiovascular disease risks through lowering cholesterol, lowering diabetes by losing weight, and changing diet?
You may also want to look at asking questions specific to your conditions as they relate to the coverage of a potential plan. I hope this helps you navigate open enrollment this year.
Gretchen’s Epi-Paleo Tenacity
Here is Gretchen’s own story from her blog:
Who am I and why Your Paleo Healthcare? Hello, for those of you who don’t know me, I’m Gretchen Bronson. I’ve been on a journey through the healthcare system for the past 13 years. Like many of you reading, I found myself discouraged by the inability of the current medical system to help me solve my medical problems. I’ve had migraines and asthma for more than 30 years, and after leaving the Air Force, I’ve been battling weight issues. To top it all off, the Veteran’s Administration diagnosed me with fibromyalgia, Chronic Fatigue Syndrome, Polycystic Ovary Syndrome (PCOS) and bipolar disorder.
In 2004, I began to take ownership of my healthcare by searching out doctors who could assist me and help me leverage the health insurance I had. The biggest thing I’ve learned on this journey is how to leverage my health insurance to my benefit. I’ve figure out how to get labwork covered 100 percent, in addition to all medical treatments. I’ve also cracked the code for successfully appealing medical claims.
On this journey, I’ve seen improvement in my health in small increments. The first improvement came in 2004 when my VA Medical Center neurologist sent me to a local chiropractor and recommended I go gluten-free. Just with the change of going gluten-free, I saw my migraines decrease from 6-8 events per month down to 4-5 per month. I’ve had migraines since the age of 10, and I had learned to live and function with them, but having the frequency drop just by eliminating a specific food was an epiphany for me. I realized at this point how important food is for overall health and wellness.
Then next phase of my journey began when I found Mark’s Daily Apple. I bought Mark’s book the Primal Blueprint, and I took a primal leap. Going 100 percent grain-free was easy. The hard part was kicking the sugar from my diet. I was addicted to sugar. It took me almost four months to completely kick sugar to the curb. Once I did, I saw improvements, and by February 2011, I was out of maternity clothes and in size 12 pants. For the first time in my life, weight loss seemed to be easy. But then I stalled out in my weight loss and became frustrated.
After trying everything under the sun to help me continue losing weight, I found Dr Jack Kruse’s Leptin Reset. Not only did I follow the reset, I began voraciously reading every word Jack blogged. It all made sense for me. So I embraced it, and things started happening. My energy changed, my perspective changed, I felt healthier. Some of Jack’s ideas were crazy and out there, sure, but nothing else was working with regards to my health, so I gave crazy a try, and it’s working! I’m seeing health improvements, and I’m uncovering the biggest impacts to what’s going on in my health the health of my family.
During this time, I was also able to find a primary care physician who embraced the paleo lifestyle and had a five-star rating for treating familial hypercholesterolemia from my health insurance. I also found an anti-aging doctor, Dr. Dzugan, who has a proven track record using bio-identical hormones to help control and eventually eliminate migraines! Suddenly things all started coming together. I started making great gains with my health, and I was able to leverage my health insurance to cover at least 85 percent of my medical expenses.
I’m going to share with you as I continue on my journey the things I’ve learned that helped me leverage my health insurance and launch the recovery of my health. I look forward to showing the things that I’ve learned and hope you’ll be able to take my experiences and apply them on your own journey to health and wellness.
More Support: Webinars by Dr. Kruse
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