Health insurance is a necessary evil, especially for us ostomates. Selecting health insurance is one of those unavoidable things that comes around once a year. It’s a big decision and it can be so hard to get information from insurance providers or healthcare providers about what the actual cost of your supplies, procedures and appointments will be until AFTER you’ve signed up for an insurance plan.
While I can’t tell you which plan you should choose, and am in no way an expert on health insurance,I figure I’ll at least share my understanding of the system and how I go about choosing my plan. This is only relevant for folks in the American health insurance market, but hopefully this helps bring a little clarity for you.
If you don’t get insurance through your employer you have a couple options for making sure you’re covered. Some labor unions, organizations, clubs and associations offer group insurance plans for their members. If none of these are in your life, you can buy an individual plan directly through an insurance provider or insurance agent, or you can get an individual plan through the Affordable Care Act’s (ACA) health insurance exchanges (marketplaces).
The ACA marketplaces offer open enrollment for 2019 health insurance coverage from November 1 to December 15, 2018. The sooner you start, the more time you’ll have to do some research and make an educated decision about which plan would be best for you. When you log onto their website you can compare plans and see if you qualify for any subsidies to help make your monthly payments lower.
If you’re getting health insurance through your employer, open enrollment is probably happening around now too. Either way, you probably have “sign up for health insurance” on your to do list, and that means you have some decisions to make for your 2019 coverage.
From the perspective of an ostomate, there are a couple things to consider when selecting what kind of plan you’d like. The most important things to me are durable medical equipment coverage, the out of pocket maximum, and coverage of my preferred hospital system.
The single biggest question I had about health insurance with an ostomy was about how ostomy supplies are covered. Ostomy supplies are considered durable medical equipment. Many plan breakdowns have a line item for durable medical equipment, but if the one you’re looking at does not have a line item, call and find out what their coverage is. Ostomy supplies can cost a pretty penny, so finding a plan that provides pretty good coverage can be really important for ostomates.
Common Health Insurance Plan Types: HMOs, PPOs, HDHPs
Most companies and the Marketplace offer HMO (Health Maintenance Organization), PPO (Preferred Provider Organization) and HDHP (High Deductible Health Plans) plans.
HDHPs:
High Deductible Health Plans (HDHP) are exactly what they sound like. They have high deductibles before they start covering your health costs. Typically HDHPs have lower monthly premiums and are recommended for really healthy people who don’t anticipate going to the doctor outside of their annual wellness exam.
HDHPs often come in conjunction with Health Savings Accounts (HSA) that you can contribute pre-tax money to. Some employers may also contribute to your HSA for you. Money in HSA accounts can earn interest and rolls over year after year for you to use on qualified medical expenses, including ostomy supplies.
Because of the HSA, HDHPs can be kind of a good deal for people who tend to max out their health plans each year because you put pre-tax money in your HSA and get the extra money from your employer to help cover your costs. The other possible benefit to a HDHP is that your pre-tax contributions lower your taxable income. These benefits are only financially relevant if the HDHP is competitive with the PPO and HMO in maxed out costs, and you anticipate maxing it out.
Other plans sometimes offer Flexible Savings Accounts (FSA), which are also tax free accounts for money to be used toward medical expenses. Some employers might contribute to your FSA. The funds put into a FSA usually have to be spent within the year they are deposited and do not roll over to be used the following year. Some employers allow a short grace period into the next year or a little bit of money to carry over into the next year, but ultimately these accounts are use it or lose it money so it’s good to do some serious calculating before putting your money into them.
HMOs:
HMOs are plans which offer coverage only to their network of providers. Because they have a limited network, the costs are often a little bit lower (this includes monthly premiums and out of pocket costs) than for a PPO.
A disadvantage to using a HMO with an ostomy is that they can be kind of limiting if you find yourself needing supplies or treatment that aren’t covered in their network. I’ve heard that some HMOs only cover certain products from certain manufacturers, so make sure you do your due diligence to confirm that you can get the supplies you need if you’re leaning toward this plan. I’m sure it’s possible to fight declined claims for supplies you need and win, but fighting with insurance is not how anyone wants to spend their days.
Another disadvantage to HMOs is that you typically have to go through your primary care practitioner (PCP) to get a referral for a specialist before seeing the specialist (which is more time and money you spend toward getting treatment). When your PCP doesn’t give you a referral you believe you need, you may not receive the medical care you need. Also, HMOs typically do not cover anything outside of network, except when they determine your visit was a true emergency.
Many people love their HMOs for their price, navigation, and because the HMO takes care of all of the claims so there’s less paperwork.
PPOs:
PPOs are plans which offer a wider network of coverage and allow you to see out-of-network practitioners as well. Out-of-network practitioners are not covered to the same extent in-network is, and your end costs would likely be higher than if you’d visited an in-network practitioner. With a PPO, you can make an appointment with a specialist directly, without a referral from a PCP. This is a plus for people who see multiple specialists or already have a team of professionals that are not all covered by the same hospital system.
Because of the flexibility offered by PPOs, their monthly premiums are often higher than the HMOs. A disadvantage to PPOs is that it can be challenging to predict your out of pocket costs.
How to Choose Which Plan to Enroll in
To get the best bang for your buck, a little bit of math weighed with your anticipated healthcare needs and whatever else is important for you in your insurance plan can help you figure out which plan would be best.
For the math, pull up the plan cost breakdowns for each of the plans you’re considering.
We’ll start by calculating the cost of the HDHP:
-Add up the expenses for 12 months of premiums + out of pocket maximum + amount you’ll contribute to HSA.
-Subtract the amount your employer will contribute to the HSA.
-This is the “total cost of the plan” if you maxed it out.
Next, we’ll calculate the cost of the HMO and PPO plans you’re considering:
-For each individual plan, add the expenses for 12 months of premiums + out of pocket maximum + FSA contributions if you plan to contribute to a FSA.
-These will be the “total costs” of each plan, if you maxed them out.
Compare your total costs and think about what a typical year of healthcare looks like for you. Be sure to consider any other planned healthcare procedures and visits you have for the next year.
Do you expect to max out your healthcare plan with your planned healthcare needs and/or have a tendency to find yourself with unexpected hospital trips or healthcare bills?
If the plans are pretty close in cost, it’s probably worthwhile to choose the plan that has the best coverage for your needs. Factors to consider might include whether you frequent the ER, buy a lot of supplies, or have a lot of specialist appointments.
Ultimately, we each have different needs and preferences for our health insurance. My hope is that this sheds a little bit of light on how to select the plan that is best for you. Don’t be afraid to contact your prospective insurance providers with your questions and to reach out to your favorite doctors to confirm they plan to accept the insurance plan you’re leaning toward.
Know something about health insurance that I didn’t mention? Let us know in the comments!