The deadline for choosing an individual health insurance plan is coming up, and besides struggling with the government’s website, HealthCare.gov, consumers are getting bogged down in another problem — picking a plan.
“Plan designs are varied and complicated,” said Stacey Pogue, senior policy analyst with the Center for Public Policy Priorities in Austin. “Every single plan is different.”
Consumers have until Monday to buy a new policy to take effect Jan. 1. Open enrollment for 2014 will end March 31. Consumers must apply for a health policy through the website to qualify for federal subsidies, which will reduce premiums for those who qualify based on their income.
For professional help in sifting through the options, consider asking an insurance agent who specializes in healthcare plans. Agents receive a commission for each plan sold, but the carrier pays it, not the consumer.
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“Consumers are, in a way, leaving money on the table if they don’t seek the assistance of insurance professionals in shopping for coverage that best meets their needs and preferences,” said Mark Bellman, president of the Texas Association of Health Underwriters.
Pogue said such agents will play an important role in the rollout of the healthcare law.
“They are a great resource to go to for picking a plan because they understand the ins and outs of all these plans,” she said. “We need the agents on board.”
Benefit advisers must maintain a required level of expertise, Bellman said, and they offer both experience and insight.
“Health agents are required to meet strict state-level exam-based licensing laws and annual continuing-education requirements, as well as significant federal and state privacy, security and market-conduct requirements,” he said. “Our membership has gone up this year because agents are looking for education on the healthcare law.”
To find a local agent, consumers can use the directory at www.tahu.org, which lists 1,800 members, including 600 in Dallas-Fort Worth, Bellman said.
On the healthcare website, consumers in Tarrant County have 36 plans to choose from — 11 bronze plans, 13 silver plans, 10 gold plans and two catastrophic plans.
Insurers include Blue Cross Blue Shield of Texas, Aetna and Cigna Health.
Bellman said there are many more individual plans and carriers outside the exchange.
“The only reason to go to the exchange is if you qualify for the subsidy,” he said. “An agent can help you find more plan options outside of the exchange.”
Agents will also conduct a cost-benefit analysis on the plan and see how it fits your needs, Bellman said.
“If you specialize in health insurance, you know where the sweet spot is for rates and plan designs,” he said. “No plan fits all people.”
Bellman said the No. 1 issue for consumers picking a new plan is retaining their doctors and hospitals. He warned that your doctor and hospital may not be in a new plan, even if you choose your previous carrier.
“For carriers to compete on the exchange, they have had to narrow their network offerings,” he said. “I’ve seen the same carrier on the exchange offer one-third of the doctors than they previously had in network and one-half of the hospitals.”
While smaller networks are one thing to watch for, many consumers will enjoy richer benefits than they had before.
Pogue said the federal law, known as Obamacare, requires 61 preventive-health benefits to be covered before the deductible, co-pays and co-insurance are met.
That’s a wide variety of services, with 15 benefits for all adults, 21 specific to women and 25 specific to children. The no-cost coverage includes immunization for all major diseases, colorectal screenings for those 50 and older, mammograms for women older than 40 and osteoporosis screening for women older than 60.
Also included are annual screenings for diabetes, HIV, cholesterol and depression. Other covered services include diet counseling, cessation intervention for smokers and contraception for those covered by a plan not affiliated with a religious group.
For a complete list of what’s covered, go to 1.usa.gov/Jcmp8D.
Bellman said a health insurance agent can assess whether it’s best to keep your plan or move to one with more benefits.
Jackie Spragins, an individual health agent with Fort Worth-based Higginbotham, said most of her clients are sticking with their old plans for next year.
“The new plans are too expensive unless you have a subsidy,” she said. “But I have done a lot of spreadsheets comparing the old and new plans for my clients.”
Full maternity coverage, a requirement of the new plans, is something to consider if you plan to have a baby in 2014. Also, catastrophic coverage and a guarantee that you not be denied coverage because of a pre-existing condition are elements of the new plans, Spragins said.
“I have one client who needs a kidney transplant and switched to a new plan,” she said. “His name came up on the list for a new kidney in January, so for the price of one premium, he will get a $300,000 claim.”
Spragins said patients who are switching plans should act as soon as they get the information from their agent.
“I have some people just now making their decisions and they’ve had the information since October,” she said.
BY THE NUMBERS
Health exchange information for Texas (through Nov. 30)
Completed applications: 118,577
People covered: 244,695
Receiving federal subsidy: 62,321
Still uninsured: 6.4 million
Sources: Health and Human Services Department, Kaiser Family Foundation, Center for Public Policy Priorities
PICKING A PLAN
• Find out if your preferred doctor and hospital are in the plan’s network. Many of the new plans have smaller professional networks.
• Determine what you must pay out of pocket for deductibles, co-pays and possibly co-insurance.
• Make sure the plan covers medical services or benefits that you require or may need.
• Make sure the plan covers your prescriptions.
• Ask about processing time and what will happen after you apply.
• To find a local health insurance agent, go to www.tahu.org
Source: Texas Association of Health Underwriters