‘Tis the season, though not necessarily to be jolly – unless you’re really into parsing the pros and cons of health plans during Colorado’s open enrollment.
Yes, the health care insurance open-enrollment season is upon us in Colorado. For those with employer-based health insurance plans, it’s an opportunity to reassess the costs and benefits of your current workplace’s offerings. Those on the state’s Connect for Health Colorado health insurance exchange have even more choices to comb through during the Colorado open-enrollment period from Nov. 1 through Jan. 15. Even if you like your existing coverage, don’t forget to re-enroll.
Before sharing some tips on choosing the right plan, a quick note: If you’re seeking coverage through the state exchange, and you want a plan that includes UCHealth, CU Medicine, and other in-network affiliates, you’ll have two options for the 2022 plan year: Anthem Pathway and the new Oscar Colorado Partners Choice, which are available in the metro Denver area. For more information on selecting a plan through Connect for Health Colorado, click here.
How to choose health insurance
Now, about choosing the right plan for you and your family. Broadly speaking, it’s a process that involves balancing the amount of care you figure you’ll need with what you’re willing or able to spend on that care. The “amount of care” is defined by the size of the network of health care providers one can choose from; the flexibility of going straight to a specialist without a primary-care referral; the extent of drug coverage; and the frequency, scope, and duration of care covered by insurance.
How to decide health care needs when choosing a plan
First, understand your own health care needs. Do you use expensive medications? Do you need a lot of care? Are you expecting a baby? Do you need a surgery? Do you have a chronic condition? Has there been a cancer diagnosis? Do you have young kids who may well end up with some sort of crud or playground injury? Do you travel abroad (and want coverage if something happens there)?
Understanding health plan providers and networks
Second, consider whether you have preferred providers – ones who know you well and whom you trust – and whether those providers are in the networks you’re considering. That includes your primary care physician and all of your specialists as well as your preferred hospitals, ancillary locations, and clinics. If those providers are out-of-network, your insurance plan may not cover them.
How to pick and choose health insurance
Third, with the above in mind, consider the class of health insurance plan you’re interested in. This step will include price tags and lets you start comparing costs. Health maintenance organizations (HMOs) require you to stay in-network for everything but emergencies and typically require referrals for specialty care, but tend to be less expensive. Preferred provider organizations (PPOs) have wider provider networks, don’t require referrals for specialist care, and let you go out-of-network for care (although that’s more expensive than in-network care). Less common are exclusive provider organizations (EPOs), point-of-service (POS) plans, which combine aspects of HMOs and PPOs.
Comparing health insurance plans
Fourth, once you understand your own likely medical needs and a rough range of costs you’re willing to shoulder, it’s time to start targeting specific plans. That involves comparing what you’ll certainly spend on fixed monthly premiums with what you may or may not spend on your care based on how much care you actually end up needing.
“Consider the aggregate total cost,” said Brandon Elliott, Director of Hospital and Transplant Contracting at UCHealth. “You should compare the costs among the plans, including premiums, deductibles, copays, and co-insurance.”
Strike a balance between costs and coverage
There’s no universal formula here, though in general, it’s safe to say that those who need consistent care, frequent specialist consults, or pricey medications are probably better off spending more on premiums to minimize deductibles, co-pays, and out-of-pocket maximums.
For the rest of us, the health insurance purchase decision is trickier, and, assuming your budget can handle more than the most basic options (low premiums, high deductibles, and lofty out-of-pocket maximums) the right plan will depend on your overall health, your habits, and your risk tolerance.
A young, healthy person who may not need a doctor’s visit more than once a year might be considered a lock for a high-deductible, high-maximum plan. But that same person may also be an avid snowboarder. Catch an edge and that high-deductible plan no longer looks like such a great deal.
There’s also the question of the level of care and the associated costs of the unexpected happening. If a snowboarding mishap leads to the need for a complex wrist reconstruction, and the services of a fellowship-trained orthopedic surgeon specializing in the procedure you need for a full recovery are out-of-network, you could be on the hook for thousands of dollars out of pocket.
You may not snowboard, but you probably do drive a car. Playing the odds can save you a bundle. If you’ve reasonably assessed your medical needs, your budget, and your lifestyle, you can position yourself to strike a healthy balance between health insurance coverage and cost. If that’s not quite reason enough to be jolly, it should at least bring peace of mind.