|By Scott Powers, Orlando Sentinel|
|McClatchy-Tribune Information Services|
Through the Obamacare exchange that opened
So where do you begin? Experts say you should know yourself first.
Do you have a doctor you really like? Chances are your doctor is listed in the provider "networks" -- health insurance lingo for an insurance company's list of participating doctors -- for some plans, but not all.
Do you take any medicine regularly? All plans must accept at least one kind of medicine in each health-care category, but not every drug, so some plans might require you to switch.
Do you have a chronic condition? One of the biggest selling points of the Affordable Care Act is that pre-existing conditions, including cancer or diabetes, must be covered. But there are ailments that are not recognized in every plan, such as TMJ chronic jaw pain (temporomandibular disorders.)
"The good news is, under the Affordable Care Act, all these plans are required to provide you in plain English a summary of a plan's coverage," said
Once you get those questions nailed down, you're ready to shop. For the first time in health insurance, the shopping is available in a way in which you can compare plans, their prices, their coverage and their networks side-by-side, said
"There are a few things they need to compare, not just one individual piece: the premium, the deductible ... benefits for services, for office visits, outpatient, inpatient, what does the deductible apply to?" she said.
The "premium" is your monthly bill, and your choices can be higher or lower depending on what the plan covers and what the out-of-pocket fees will be for medical visits.
"The first question I ask is: 'What can you comfortably afford to spend every month?' After we get over the 'Ha! Ha! Nothing!' answer, we get to the real amount," said insurance broker
The next question she asks is: How healthy do you expect to be next year?
The "deductible" is the amount of money, most commonly
"That 25-year-old, healthy single guy or lady, [who] never had any history of medical problems, they probably could take a little bit higher risk" and accept a higher deductible, said
"Versus that person with a spouse and four children," who may want a lower deductible, he added. "If you have children in sports, they're going to be in the emergency room."
The "co-pay" is what you'll routinely pay each time you visit a doctor, a fixed price negotiated by the insurance company usually in the
A "fee-for-service" is what you'll pay for non-routine problems, including diagnostic tests and hospitalization, that are not covered by co-pays. Again, the price would be negotiated by the insurance company and therefore would be less than "retail" prices but could run hundreds of dollars or more.
Some organizations including HMOs (health maintenance organizations) and EPOs (exclusive provider organizations) are set up to keep costs down, but you probably can only go to family doctors, specialists and hospitals in their networks. Their payments to doctors usually are "capitated," meaning doctors collect a flat fee per capita -- for each patient seen, and no more, regardless of what they do.
The "non-capitated" organizations such as PPOs (preferred provider organizations) allow your family doctor more flexibility in billing for what care is actually provided, but your co-pays will be higher. PPOs also allow your doctor to be the "gatekeeper," sending you to out-of-network specialists and hospitals if he prefers them, but you might pay a little more.
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(c)2013 The Orlando Sentinel (Orlando, Fla.)
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