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Choosing a Healthcare Plan

21 Oct 2021 7:38 PM | Amy Thomason (Administrator)


by Elizabeth Jane Brooks, LMT, BCTMB

With open enrollment just around the corner, some helpful information for your consideration is below. This information will help self-employed individuals choose a healthcare plan that is best for their needs in the upcoming year. Open enrollment begins on November 1, 2021 and ends on January 15, 2022. A few things to consider:

  • The 4 categories: Bronze, Silver, Gold, and Platinum

  • Type of plan you like: HMO, PPO, EPO, or POS

  • If you want a Health Savings Account (HSA)

  • Your total out-of-pocket cost

The 4 Categories


Bronze

Silver

Gold

Platinum

Insurance pays

60%

70%

80%

90%

You pay

40%

30%

20%

10%

Premium

Lowest

Moderate

Higher

Highest

  • Bronze plans are a good choice if you want to pay a low premium and only want to be covered for major illness/accidents. Since these plans are eligible for a Health Savings Account, your routine care (which is not covered by the Bronze plan) could be paid from the HSA.

  • Silver plans are a good choice if you don’t mind a slightly higher premium and have more routine care coverage. They are also eligible for a Health Savings Account.

  • Gold plans are a good choice if you use a lot of medical care and are willing to pay a higher premium than the Silver plans, and are wanting more costs covered. These plans are not eligible for an HSA.

  • Platinum plans are a good choice if you need a lot of medical care and are willing to pay a high monthly premium. These plans are not eligible for an HSA.

Types of Plans

  • Health Maintenance Organization (HMO)
    With this type of plan you must stay within their network. A primary care physician manages your care and will give you the necessary referral to see a specialist if needed. If you see a provider that is out of network, you will have to pay the full bill yourself (e.g. a cancer specialist, a favorite cardiologist, etc.).

  • Preferred Provider Organization (PPO)
    You have the freedom to see any healthcare provider with this plan but you will pay a higher percentage for out-of-network providers. In addition, there is usually a higher deductible for out-of-network providers.

  • Exclusive Provider Organization (EPO)
    This plan only covers in-network providers, and there is no need for a referral for specialists from your primary care physician. It’s important to know beforehand whether all of your providers (e.g. your anesthesiologist during a surgery) are in-network so you are not surprised by a high bill. 

  • Point-of-Service Plan (POS)
    You can see both in- and out-of-network providers with this plan; however, you will pay a higher portion for out-of-network. Your primary care physician coordinates your care and provides the referral if you need to see a specialist.

  • Catastrophic Plan
    This is for those under 30 or those who qualify for a “hardship exemption.” This plan offers a lower premium, free preventative care, and 3 primary care visits, even if your deductible has not been met. This plan’s deductible is $8,550 for an individual and $17,100 for a family in 2021. After you reach the deductible the plan pays 100% of covered medical benefits.

  • High-Deductible Health Plan (with or without a Health Savings Account)
    This is similar to the Catastrophic Plan in that it has a lower premium. The deductible begins at $1,400 for an individual or $2,800 for a family, but not more than $7,000 for an individual and $14,000 for a family in 2021. Preventive care is free even if you haven't met your  deductible.

Health Savings Account (HSA)

This is a savings account used for medical expenses when you have a healthcare plan that has a deductible of $1400 for an individual and $2800 for a family. Money left in your HSA account at the end of the year is not lost and will carry over to the next year. If you rarely go to the doctor, an HSA account can be used to build up savings as you are able to keep all monies invested until you decide to use it for medical expenses, tax free. With deciding plans, note also that out-of-pocket costs include deductibles, copayments, and other amounts (but not premiums).



Single Plan

Family Plan

Max contribution

$3,650

$7,300

Catch up contribution

$1,000

$1,000

Minimum deductible

$1,400

$2,800

Maximum out-of-pocket 

$7,050

$14,100


Deciding Factors in Choosing a Plan 

  • Health: How healthy are you? If you are very healthy, a bronze or silver plan may be sufficient for you. If you have a major illness you would most likely be better off with a gold or platinum plan which would give you more coverage.

  • Medications: If you have expensive medications necessary for maintaining your health, you want to make sure those particular medications are covered by your plan.

  • Networks: Do you think you may need any out-of-network providers for the upcoming year? Is your primary physician in- or out-of-network for a particular plan? You will want to make sure that your favored providers are in-network to reduce your out-of-pocket costs.

  • Area of Coverage: People who enjoy backcountry sports, such as mountain climbing or backpacking, and people with significant health issues that may require transport to a city hospital in an emergency, need to make sure their plan covers them should they need airlifting. You don’t want to be surprised by a $20,000+ bill, so consider where you live, work, and play, and the ramifications of needing care in those situations.

  • Total Costs: After considering your circumstances and individual needs, determine which category you would like (Bronze, Silver, etc.) and the type of plan you prefer (PPO, EPO, etc.). Then, take your maximum out-of-pocket expenses and add your annual premium expense. This number gives you the total possible cost for any plan. 

WSMTA hopes this article makes your choice for a health care plan a little bit easier for you.


Resources:

Health Plans

Brokers

HSA allowable expenses



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