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Choose Health Plan With More Than Pocketbook In Mind

If you’re not already in the midst of picking your health coverage for next year, you soon may be.

If at all possible, please don’t base your decision solely on the cost of monthly premiums.

Let’s say you have asthma. Out of 10 major Health Maintenance Organizations (HMOs) recently ranked in California, three received a “poor” rating for asthma care, five were ranked “fair” and two got “excellent.”

You might want to know which is which.

“If you have substandard care … through your health plan, paying any amount of money is not a good trade-off,” says Beth Abbott, director of the state Office of the Patient Advocate (OPA), which provides the rankings. “People should consider the interaction of both cost and quality.”

Today I’ll point you to some resources that will help you compare plans on their care and patient satisfaction.

I also want to acknowledge again that while costs are definitely a critical component of your decision, don’t make premiums the only criteria.

Q: I have health insurance through my employer and open enrollment is coming up. It would make my life easier just to stay in the same plan I’m in. Is that a good idea?

A: Don’t automatically assume that the plan you’re in now will be the best plan for you next year.

Why? Doctors fall in and out of networks. Premiums, co-pays, and deductibles often rise. And your plan might not provide the best care for your current medical needs.

Let’s start with some basics. For most people, open enrollment will be the only chance to buy or change your health insurance each year. But the timeframe depends on where you get it:

  • If you have job-based insurance, you usually enroll for the coming year during the fall. Check with your human resources department for exact dates.
  • If you buy individual or family plans from the state health insurance exchange, Covered California, or the open market, open enrollment for 2016 starts Nov. 1 and ends Jan. 31, 2016. If you already have a Covered California plan and want to stick with it, you can start the renewal process now.
  • Open enrollment for Medicare recipients began Oct. 15 and ends Dec. 7. Medicare is the federal health insurance program for people 65 and older and those with kidney failure and certain disabilities.
  • You can enroll in Medi-Cal, the state’s version of the federal Medicaid program for low-income residents, any time of year if you’re eligible.

The biggest chunk of insured Californians have private insurance, either purchased through their employer or from Covered California or the open market. I’m going to focus on them.

The OPA report cards (find them at grade the health plans and doctor groups that serve more than 16 million Californians, most of whom get their insurance through work.

Recently updated for 2015-2016, they offer two categories of ratings.

  • Member satisfaction: Patients rank their health plans and doctor groups on customer service, ease (and speed) of obtaining care and other measures.
  • Clinical data: These rankings measure whether plans meet recommended care guidelines in a number of areas, including diabetes, maternity, heart and mental health care.

The plans differ dramatically on some measures. For instance, as with asthma, HMOs rank from poor to excellent when it comes to maternity care. Drill into the rankings to learn which plans do better at prenatal and post-birth visits than others.

Beyond rankings, if you click on a health plan’s name, you can inspect customer service options and hours, which can be critical if you’re dealing with a sick child in the middle of the night and need advice, Abbott says. Some are open 24/7, including weekends. Others only answer the phone from 8 a.m. to 5 p.m. on weekdays.

“Some don’t have an after-hours number you can call,” she says.

If you’re buying insurance from Covered California, the agency this year will offer some plan ratings based on enrollee experience and opinion, not clinical data. You can find those star ratings when you’re shopping for plans on its

If you’re looking for clinical data, use the OPA report cards as a proxy, Abbott suggests. But beware that insurers sell different plans to their job-based customers and Covered California enrollees. Doctor networks, price structure and other factors differ.

Now, back to cost.

Don’t ignore the amount of money you will owe when you actually receive care, such as the deductibles, copays and other out-of-pocket costs that can easily climb into the thousands of dollars. (A deductible, for instance, is the amount you owe for covered health care services before your insurance starts to pay.)

In general, the health plans with the lowest premiums have the highest out-of-pocket costs.

In Covered California parlance, that’s a bronze plan. For 2016, an individual who buys a basic bronze plan will face a $6,000 deductible for medical costs and $500 for drugs, which equals the plan’s $6,500 out-of-pocket maximum. (Double those figures to get the family limits.)

People with job-based plans, too, are getting hit. A recent Kaiser Family Foundation analysis of workplace benefits found that both the share of workers with deductibles and the size of deductibles have spiked. Together, they account for a 67 percent increase in deductibles since 2010, dwarfing the rise in premiums, workers’ wages and general inflation.

If you’re considering a high-deductible plan because of its lower premium, do the math ahead of time and understand all of your financial obligations, says Lucien Wulsin, executive director of the Insure the Uninsured Project, which advocates for California’s uninsured population.

If you’re a Covered California customer in particular, Wulsin urges you to check if you’re eligible for an “enhanced” silver planbased on your income. These plans offer subsidies that lower your out-of-pocket costs, but you must choose the silver level to receive them.

“When people are choosing these plans, they have to have their eyes wide open,” he says. “You can say, ‘I’m healthy today,’ then have an accident tomorrow.”

In other words, how many of you have $6,500 lying around for your next unplanned visit to the ER?

Provided by the Center for Health Reporting at the University of Southern California.

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