If you’ve ever felt uncertain or overwhelmed when trying to make a decision about your health insurance, you’re not alone.
From the confusing alphabet soup of terms—HMO, PPO, HSA and so many others—to the maze of options for doctors, hospitals and prescriptions, there are plenty of reasons anyone might feel bit lost.
The wide range of choices and technology to treat all sorts of medical woes continues to expand and improve, says Dr. Sima Kahn, president of the National Association of Healthcare Advocacy Consultants. But having all these options presents a conundrum.
“It’s a wonderful thing for all of us in terms of our health and living longer and living better,” she says. “But what it means is there’s no way anyone needing a doctor can keep track of all the medical knowledge.”
It’s been six years since the Affordable Care Act was signed into law, and more Americans than ever before have health care coverage.
Sorting out how to get the best care for the best value is a challenge that doesn’t come with a one-size-fits-all solution. Experts say it’s important to take stock each year of your health, your family and your goals—and don’t be afraid to ask questions.
Kicking off your career
Great news: You’ve landed your first job! Even better: It comes with a health plan. But which box should you check on those forms from HR, the one that says traditional or the one for the high-deductible plan?
A traditional plan will cost more in monthly premiums than a high-deductible plan, but if you end up facing substantial medical bills, more will be covered. A high-deductible plan will leave more money in your paycheck, but will require you to pitch in more if you get sick or injured.
HDHPs also often come with help from your employer—a contribution to a health savings account. There, you can deposit money from each paycheck, tax-free, and spend it on medical bills, prescriptions and other health costs.
An HDHP plan could be a good bet for someone who doesn’t anticipate spending much time in the doctor’s office. Maybe you only pop in for an occasional sinus infection, so you don’t expect to much out-of-pocket.
These plans are popular among young single people, but may also be an affordable choice for families or even older users.
If you consider an HDHP, remember that it’s paramount to get a plan you’ll feel comfortable using, says Janice Klein, director of business for Mt. Lebanon School District in suburban Pittsburgh. She says saving money is great—unless it’s at the expense of your health.
“One of the worst things people can do is get the high-deductible plan and then choose not to see doctors because the first dollar of payment comes out of their pocket,” Klein says. “Then when they do go to seek care, they’re sicker.”
You’re combining everything, from your closet space to your bank accounts, so why not health insurance? For some couples, it makes sense for one partner to get coverage under the other’s insurance plan.
But Klein says it’s worth taking a close look at both plans because it could end up being cheaper for each half of the couple to keep his or her own insurance.
“Sometimes it’s a benefit, sometimes it’s not,” she says.
Alternately, it could be a good time to assess just how well both or either of the plans stack up against the options available through the government exchange.
“What you get at your place of employment may or may not be the cheapest thing out there,” Klein says.
“Look at your deductibles, because some people have very high deductible plans at work, and they’re not being paid completely. You may be eligible for a subsidy through the federal government that you wouldn’t be able to get at work.”
Starting a family
Maybe you haven’t seen the inside of a doctor’s office in years. But now that you have kids, you’ll be visiting more often—and getting bills more often.
If you’re not already familiar with all the specifics of your plan, now’s a good time to do some reading. Make sure you know exactly how much you’ll have to pay for a visit to your family doctor, to a specialist, to urgent care and to the emergency room. Whether your plan calls for a co-pay in a specific amount or as a percentage of your fees, the bills can add up.
Rick Amundson, a workplace wellness consultant with Excellus BlueCross BlueShield in Rochester, N.Y., says people often forget to add up the full cost of their plan, and don’t take into account that they could be charged different co-pay rates for their kids.
“Sometimes the one that costs less may not be the best policy for you,” Amundson says. “One of the fallouts from the (health insurance) exchange is that people are finding out that the cheapest policy might not be the best policy. It might be very basic insurance with very high co-pays. That’s why you have to think about what your own situation is.”
Facing an illness or injury
You did your research, picked the best plan, and now, it’s time to use it.
Whether you’re scheduling minor surgery or facing a frightening diagnosis, choosing the right doctor and hospital can feel like a daunting task. It might seem to make sense to choose the priciest option or the fanciest-looking clinic, but experts say those factors often don’t point to the best health care.
Reputation and rankings can be one factor to consider, but Klein warns that those aren’t foolproof; some hospitals pay to be part of some ranking lists. Websites like CareChex.com use federally reported data to compile quality ratings.
Kahn, the health care advocate, says it does make sense to read up on which hospitals near you are considered the best for particular specialties.
“I look for who are the really excellent physicians, and where they are, and I look for what the hospitals are known for,” she says. “I wouldn’t be looking for nice lobbies and beautiful lighting and artwork and amenities. Those are really nice, but they don’t have anything to do with how good the hospital is.”
Klein says it can be even tougher to sort out specialists or surgeons and find the best one for you. Get advice from your primary care physician—he likely knows what’s appropriate for you, your attitude and your pocketbook. Some insurance plans offer ancillary services through vendors that can help people find a doctor for a second opinion.
If you’re uncertain about what tests you need, Kahn suggests consulting an online database that tracks the most frequently ordered tests and how effective they actually are. A search on ChoosingWisely.org can help provide some clarity on what tests will measure.
Thinking about retirement
If you’re heading toward retirement, or you’re still working but about to become an empty nester, you’d be wise to make sure you know where and from whom you can seek care. Some plans might cover visits to only a very limited list of doctors and hospitals in your network. That might have been fine in the past, but if you’re planning to travel or split your time between two geographic locations—we’re talking to you, snowbirds—you might find your medical bills soaring.
Amundson says he’s heard from retirees who learned the hard way that their plan didn’t cover doctor visits near their second home.
“They call me and say, ‘What’s going on? This costs four times as much in Florida?’” he says.
Another consideration: When your kids head off to college, make sure your plan has enough range to ensure they’ll be covered if they end up needing medical care far from home.
And if your prescriptions pile up, get smarter about shopping around. Jim Wagner, executive director of ARIN Intermediate Unit 28 in Indiana, Pa., says people with high-deductible plans who are spending money out of their health savings accounts often don’t bother to look for the cheapest price.
Wagner says he and his wife shop around their prescriptions once or twice per year. It can be a complicated process—one that requires calling multiple pharmacies and providing your prescription information—but Wagner says it can be well worth it.
“We’ve saved as much as $160 on a single prescription, going from $170 to $10,” he says.