Help me pick Medical Insurance.
April 20, 2012 1:23 PM   Subscribe

What factors should I consider when choosing Medical Insurance?

Insurance terminology confuses me to no end. It have a chart in front of me and it took me a while to realize I should be looking for smaller co-pay figure, not larger ones.

So my chart lists the following things: (I put some examples of values that occur)

HMO Network Required: [yes | no]
Deductible [No Deductible | $1,000/$2000 | $3,000 | $5,000 etc...]
Dr. Office Visits: [ $15 | $25 | $30 | $40 copay ]
Hospital Services: [$400 Copay Per Day | $400 Copay Per Admission]
Rx Benefit: [$15 Copay | $200 Ded. - $30 Copay ]
Out-Of-Pocket Max: [ $2,000 | $3,000 | $4,000 | $7,000 ]

So that's the data I'm working with, but I don't even know necessarily which numbers are good (I think I want most of these numbers to be as low as possible?). Beyond that, I don't know which is more important, relative to each other. (Say one has an awesome deductible but a bad Out-Of-Pocket max. Should I pick that one, or go vice-versa?)

Is there some sort of general guideline somewhere on the internet that can
1. Explain all these terms.
2. Explain whether I want big numbers or small numbers after these terms.
3. Explain which parts are more important to consider than the other ones.
4. Explain if there are other factors I should be considering.

Re. #4, the cheapest plan on the sheet is "Salud" by Health Net, and it looks like it has smaller deductible, copay, and Out-Of-Pocket Max than some of the most expensive plans. So that makes me think there is more to consider than these numbers on this sheet--is there some trick where if I get in an accident and I have Salud, that I'll end up $900,000 in debt? Why does it seem like such a good deal?

By the way, if it makes a difference, my employer is paying 95% of the cost, so the most expensive plan I can get would be $13 for me per month, and the cheapest would be $8 per month. I don't care so much about the per / month cost, I just want to be safe, and I don't want to pay a lot when I do get sick.

Also perhaps important to know: I have been to the doctor once in the last 10 years. I think I should probably start doing yearly checkups and going to the doctor more often, but generally, I don't expect to go very often, but I do want to be protected in case something happens.

Also important: I have HMO and PPO plans available to me from Anthem Blue Cross, Health Net, and Kaiser Permanente (so-cal).
posted by brenton to Health & Fitness (23 answers total) 7 users marked this as a favorite
Find out whether you'll need referrals for specialists. Not needing referrals can be a godsend when you know you need a whateverologist, and you don't want your PCP acting as a gatekeeper. Time and effort saved can trump money spent.

Anyway, here's a comprehensive looking worksheet to fill out, based on various assumptions.
posted by chesty_a_arthur at 1:26 PM on April 20, 2012

Also check out lifetime cap. If the lifetime cap is $250K, and you have a serious illness, you could blow through your insurance like that.
posted by chesty_a_arthur at 1:27 PM on April 20, 2012

If it's the difference between $9 and $13 and not, say, $300 and $1000/month, just go with the best plan they have: lowest deductible, lowest out-of-pocket, widest coverage. There's no reason not to. But here's some other info:

A deductible is how much you have to pay (per year, I believe) before they start paying whatever percentage they may. Same thing with a prescription deductible. So if you get into an accident, the first $1000 (or whatever) are on you, and then they cover a percentage of it.

Pay what you need to pay (assuming it's not an staggering difference) to stay out of HMO networks if you value your time. You might not need to go to the doctor often, but god forbid something happens you'll want to not spend the entire damn day at the doctor every time you have to go.

Yeah, lifetime cap is really important. I once had a company offer me amazing insurance, but there was like a $5,000 lifetime cap which made it practically useless.
posted by griphus at 1:32 PM on April 20, 2012

Usually, when you have lower co-pays, your premium will be higher, so you may want to take that into consideration.

Some things you might want to consider:

Health Savings Account: This is an account that you deposit pre-tax dollars into and pay co-pays and medical expenses out of. Most employers will provide for this option, or you can open an HSA on your own. Choose a bank that doesn't charge a maintenance fee for this. I live in Atlanta, my HSA bank is in Chicago.

Network: If your current GP is In Network, it harms you not at all to pick a PPO or an HMO.

Annual Check-Up: Whether Man or Woman, you should be seeing a physician annually. Many companies provide for this with an Annual Well Woman or Annual Check Up included in their benefits.

Kaiser: You'll hear a lot of stuff about Kaiser, but I was one of their first patients and as a kid, or if you have kids, they are great. You go to the big building and it's all there. Your Doc, the lab, x-ray, pharmacy and anything else you might need. Need to see someone right away? They can handle it. That someone may not be your specific doc, but trust me, when you've got hives and all you want is a cortisone shot, pretty much any port in a storm will do. Find out where the Kaiser is that you'd be using and go in there some day and wander around. If you get a good vibe, I'd go with that one.
posted by Ruthless Bunny at 1:39 PM on April 20, 2012

@griphus: I came to the same conclusion about cost, but my trouble is I don't know how to pick the "best" plan... the one that looks like it has lowest deductible and out-of-pocket is actually the cheapest, so I am a little worried about that.

In terms of wide coverage--I live in LA so I assume that all of them have providers around that I can use. Is there some particular thing I should be looking for when I evaluate their coverage? And how would I do that? Do insurers have maps of all places in their network?
posted by brenton at 1:41 PM on April 20, 2012

@Ruthless Bunny: What is a premium?
posted by brenton at 1:41 PM on April 20, 2012

I believe that Kaiser works differently than the other 2. My friends in nothern california have Kaiser and the way it works is that you go to their facilities for everything including prescriptions but I think some can be mailed. So you can check out if they have locations close by and see what the reviews are like. I've heard that experience can vary a bit in different locations.
posted by oneear at 1:44 PM on April 20, 2012

Network: If your current GP is In Network, it harms you not at all to pick a PPO or an HMO.

I'm across the country from the OP, and I know CA has a number of insurance idiosyncrasies, but I have never had a good experience with the HMO model, and I don't know anyone who has. At least in New York, getting off HMO and into the PPO system is a big deal, especially when there's kids in the equation.

...but my trouble is I don't know how to pick the "best" plan.

Do they actually give you two or three discrete selections, or is a cafeteria model where you pick and choose and calculate the cost at the end? If it's the former, what are the exact options you have?

Do insurers have maps of all places in their network?

When you sign up for insurance, they'll mail you a giant book with all of their doctors in it, usually sorted by field. There will almost certainly be a database on the company's website as well. It might be publicly accessible, too.
posted by griphus at 1:47 PM on April 20, 2012

Here's a scan of the worksheet they gave me:
posted by brenton at 1:50 PM on April 20, 2012

Its impossible to help you pick without knowing what the costs are, how old you are, and what sort of service providers do you use/have you used.

If you are 25 in good health you have a different cost/benefit analysis then if you are 50 and see a bunch of specialists regularly. Same thing with your family status.

Remember if things change you can change your enrollment yearly (or when certain family events occur)

For example if you see a therapist you need to figure out what sort of structure the different plans have to pay that person and what the difference in costs amount to.

Basically getting above the most basic plan ends up being a bad bet unless you know there is a high likelihood of demanding healthcare services above and beyond the occasional visit to the primary care physician.
posted by JPD at 1:52 PM on April 20, 2012

sorry, this is a link to the scanned worksheet:
posted by brenton at 1:53 PM on April 20, 2012

> Its impossible to help you pick without knowing what the costs are,

assume $13 for all plans.

> how old you are,

late 20s

> and what sort of service providers do you use/have you used.

I went to a minute clinic at a CVS. That was the only doctor visit I can remember for probably the last 15 years.
posted by brenton at 1:55 PM on April 20, 2012

If there was more money at stake, I'd agree with JPD. But, honestly, if you're going to end up paying $13/month (which is straight-up pocket change in the insurance game), I'd go with the Anthem PPO 4000 or HSA 2500, depending on the particulars (i.e. the difference between an $40 office visit copay and $80 of the visit covered.)

But, again, you're in CA, I'm in NY, and our HMO system is rotten to the core.
posted by griphus at 1:58 PM on April 20, 2012

(I am not an insurance expert, just a dude who finds himself at the doctor incredibly often.)
posted by griphus at 1:58 PM on April 20, 2012

The image that you posted is not helpful, since all it lists is the cost of the plans. Since your cost is effectively zero ($8 to $13 a month), this is not where you should be making the decision. If you want help deciding, we need to know what the various plans cover.

Basically, your goal is to minimize co-pays, minimize out-of-pocket maximums, minimize deductibles, maximize the amount the plan pays, maximize lifetime maximums, and maximize the freedom you have in choosing doctors. Different people are going to prioritize those in different ways.

For you, it seems like you're mostly using this as a safety net, so I'd make really sure that you have a high lifetime maximum (to cover catastrophic things).
posted by Betelgeuse at 2:00 PM on April 20, 2012

As an aside, enjoy it while you can. As a comparison, I'm in my late 40s and pay close to $500 a month, of which my employer subsidizes 80%. I consider myself lucky.

Okay, having undergone a major health scare last year, I would note that if you travel around, having a PPO is important. I live on the west coast and got sick when I was on vacation on the east coast. Had I not had a PPO, I would have been in major financial trouble because all of my costs would have been out of network - about $90,000 worth!
posted by HeyAllie at 2:00 PM on April 20, 2012

Yeah, as a point of comparison, when I started my current job I was given a choice between (pretty good, but not great) insurance or an extra $300/month.
posted by griphus at 2:02 PM on April 20, 2012

Hiya again!

The Premium is what you/your employer pay for the cost of the insurance. It's not super-relevent to you because your share of the premium is pretty small. ($13)

If you travel Kaiser is not an awesome choice. They're pretty much only in CA and GA.

My husband worked for Anthem in TN, you could do worse.
posted by Ruthless Bunny at 2:04 PM on April 20, 2012

FYI: Plans can no longer have lifetime caps under ObamaCare. Of course the status of that legislation is currently up in the air.
posted by dcjd at 2:22 PM on April 20, 2012

(actually I'm not sure, that might only apply to individual plans and not group plans)
posted by dcjd at 2:23 PM on April 20, 2012

argh... it was the wrong link again.

THIS is the right one:
posted by brenton at 2:26 PM on April 20, 2012

Rather than type it all in again, I'll link to two relevant answers I wrote to others asking a very similar questions:

How to choose a health insurance plan

Basic overview of health insurance terms and concepts

Basically, the factors you should look at from most to least important are:

1. Benefit package (what is included in your coverage)
2. Maximum yearly out-of-pocket (the most you'll ever pay, you want this lower)
3. Deductible (this is the amount you have to pay out-of-pocket before anything is covered, you want this low)
4. The in-network hospitals and docs in your area (is your nearby hospital an in-network provider?)
5. Whether you need a referral to specialists (I don't care about this but it's a big deal to some people)
6. The copayment or co-insurance for a doctor visit (after you pay the deductible, what are you still responsible for during every visit--you want this low)

People tend to emphasize the copay or coinsurance way too much when choosing policies; you should care much more about the maximum out-of-pocket (what happens in the worst case scenario) and deductible (what happens in the "somewhat serious health issue" scenario). Paying $20 versus $10 to see a doctor after you've met your deductible is comparatively a much smaller deal.

Also, the California Department of Managed Care provides report cards for HMOs with a lot of information online about consumer satisfaction and quality-of-care for all HMOs in the state. That's probably worth looking as well when you're making your choice.
posted by iminurmefi at 3:20 PM on April 20, 2012 [1 favorite]

Looking more specifically at the document you uploaded, and taking into account your concern that "I don't care so much about the per / month cost, I just want to be safe, and I don't want to pay a lot when I do get sick" (good for you, this is EXACTLY how you should think of it):

*Don't go with the consumer choice PPO plan (the HSA 2500), this type of plan requires a ton of out-of-pocket spending if something happens, and people generally only get it if they can't afford the premiums for better products

*I think you'll be better off with an HMO than with a PPO, because your PPO options all have a $3,000 or $4,000 deductible. That means if you have something moderately-serious happen, like breaking a leg, you'll almost definitely be paying $3,000-$4,000 up front before your insurance kicks in at all. In return, you don't have to meet with a primary care doc before going to a specialist. Really, you should have a primary care doc that you like and who can fit you in quickly if something bad happens, so for me it's a no-brainer to go with an HMO in terms of financial risk.

*Within the HMOs, if you have an option, you want to stick with that top tier--that's the lowest cost-sharing, so the premiums are probably higher, but since your employer is paying so much it makes sense to ignore premiums. (Note, for instance, that the Kaiser HMO 25, HMO 30, and HMO 40 are all identical except you're paying a bit more for each visit as the number goes up--$25, $30, and $45 respectively.) Again, I'd probably stay away from the Anthem HMO options for no other reason than they have a deductible and it's almost always better from a financial POV to get insurance with no deductible--then you don't have big bills up-front if something bad happens.

*Within the remaining HMOs, you have Kaiser and Health Net. In the most recent DMC report card for HMOs, Health Net got 3 stars for health care quality (meeting national standards of care), 3 stars for how members rate the plan, 2 stars for easily getting care, and 1 star for plan service. Kaiser of SoCal got 4 stars for health care quality, 4 stars for how members rate their plan, 2 stars for easily getting care, and 2 stars for plan service. Based on that alone, I'd pick Kaiser over Health Net.

Disclaimer: I am not you, there might be a better plan for you if you value total freedom to see whoever you want more than you value financial protection against future risk in case of a major medical emergency. But I study this stuff for a living and that's pretty much the checklist I would go through to pick a plan, and the plan I would end up selecting.
posted by iminurmefi at 3:38 PM on April 20, 2012

« Older An old memory of color TV?   |   I'll date you AND give you $5,000,000! I just... Newer »
This thread is closed to new comments.