Health insurance Medicare Your Coverage Options

Three reasons why you can’t choose a health plan that’s “right for you”

Written by Diane Archer

If you’re struggling to choose a health plan that’s “right for you,” you’re in good company. It’s not possible. There’s generally no way to know whether your health plan will permit you to get care from the doctors you know and trust at a price you can afford, and that’s the chief reason you need health insurance. Here are three big problems you face and two recommendations for choosing a health plan:

1. You can’t intelligently pick a private health plan based on its network of doctors and hospitals since you don’t know what your future needs will be. The odds may be against your having a stroke or heart disease or being hit by a truck, but it could happen. And, the network doctors you want to use may have left the network by that time or may not be taking new patients. Or, you might need to live with a family member away from home while you receive costly care. In all of these instances, you might need to see doctors or use a hospital not in your health plan’s network. And, your costs could be tremendous. (Keep in mind as well that you can’t trust a health plan’s provider directory.)

2. You can’t easily compare costs among health plans because you don’t know what services you will need and what the health plan will charge you for them. If you choose a health plan based simply on premiums and deductibles and your current health care needs, you could get stuck with huge out-of-pocket costs–in-network copays and coinsurance–if you end up needing costly care. And, since you usually don’t know what the insurer will charge you in copays and coinsurance before you sign up, you can’t even calculate your out-of-pocket costs for different conditions.

3. If you’re in a commercial health plan and need costly services, you may not be able to afford them. Health plans are not required to ensure that you can afford the care you need. They can set high deductibles before they begin covering your care, along with high copays for care you need. They also do not have to ensure doctors who treat you in a network hospital are also in your network. So, it’s not unusual for out-of-network emergency room doctors, anesthesiologists, radiologists and pathologists to treat you in a network hospital and for you to get stuck with unaffordable bills.

What can you do?
If you are eligible for Medicare and can afford the upfront costs, consider enrolling in traditional Medicare with supplemental coverage. You may pay more for it up front. But, if you end up needing costly care, it will likely save you money. And, it offers the greatest opportunity for coverage from the doctors and hospitals you want to use. Here are four things to think about when choosing between traditional Medicare and a Medicare Advantage plan. Health plan networks limit access to care.

If you only have the choice of a private health care plan, try to pick one with a network of good doctors and hospitals. One recent study suggests that narrow provider networks may offer as good care as wide networks; it’s all about the providers in your community and the quality of the providers in the narrow network. Check with your doctors to make sure they are in the health plan’s network and have good things to say about the health plan. To keep your costs down, you want to be able to see in-network doctors in the event you need costly care. And, if possible, set aside money or make a plan to cover your deductible and out-of-pocket costs. Too many Americans end up foregoing needed care because, even with insurance, out-of-pocket costs can be huge.

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2 Comments

  • Sorry to be the bearer of bad news.Medicare does not pay for long term care; the most they will pay for is 100 days and then only if there is a chcane she’ll get better within that time. This is why they’re reviewing the case after three weeks. This is also why everyone needs Long Term Care Insurance.Medicaid will pay. However, she’ll have to spend down her assets before they’ll pay. What this means will depend upon the state in which they live, but your mom will have to sell almost all of her assets, including stocks, bonds, and investments. If the assests are also in your dads name he may keep 50%. They can keep the house if your dad is living there but Medicaid may place a lein on the house. She’ll have to spend almost all income she receives to pay for her care. Also, if Medicaid pays they may not authorize her to be in the same home. Not all nursing homes are approved by Medicaid; they will put her in one the cheapest places around that can give her care.The only good news I can give is your dad won’t be liable for the charges once Medicaid takes over.

    • While most of what you are saying is true, each state is different.
      In California, once the Medicaid person dies, any remaining assets
      must be turned over to the state to re pay them for the expenses.

      It would be a good idea for every American to get involved with the costs of medical care as the inflationary spiral will bankrupt us all before we leave this earthly plane.

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