Open Enrollment Options in the Affordable Care Act

By John Fulton

Editor’s Note: John Fulton has been through many years of treatment for various types of cancer since he was 15 years old. Now at age 56 he still travels out of state for some medical services. Who better to write about the vagaries of obtaining health care insurance? He was asked to write about the options for the open enrollment period that comes to a close on December 15. Some patients of Bronson Family Medicine of Vicksburg will have to change their provider because Bronson Hospital does not accept some forms of traditional coverage.

The 2018 open enrolment deadline for health insurance through the Health Insurance Marketplace is December 15. This is fast approaching with just a few days remaining. Current law requires individuals to purchase health insurance through the Marketplace if not already covered through an employer, Medicare, Medicaid, Children’s Health Insurance Plan (CHIP) or other qualified coverage. If you do not have coverage there may be a penalty or fee. Coverage will begin January 1, 2018.

The Federal Government offers tax credits for insurance premiums depending on income and family size. Many applicants will be surprised at how high a person’s income can be to qualify for a tax credit. There are a wide variety of plans, but all cover essential health benefits, pre-existing conditions and certain preventive services.

2018 Open Enrollment is Here – and It Ends on December 15.

It is extremely important to enroll during the open enrollment period. If not enrolled by December 15, the open enrollment opportunity ends and you will have to wait another year. There are some enrollment exceptions for major life changes such as marriage, divorce, births and loss of a job that provided coverage. Part of enrolling is providing income information to calculate if a subsidy is available.

For this writer, the hard part when covered through the Marketplace was determining the enrollment sweet spot based on the premiums and estimating what my medical expenditures would be for the coming year. Part of the calculation involves personal medical risk assessment and an individual’s tolerance for paying higher deductibles versus lower premiums.

If you are healthy and consume few medical services you may choose a lower premium and risk higher deductibles, copays and coinsurance limits. Stay healthy, you win. Find yourself in a medical crisis, you will wish you had picked the higher premium with lower deductibles.If you use lots of medical services you will need to do some math calculations to find the sweet spot of deductibles versus premiums that make the most sense based on your individual situation and comfort levels.

Picking between a Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) is another big decision you will need to be thinking about. Again, it is partly based on your need for medical services and risk tolerance. There are many differences in the two plans that you will need to research, but a couple of things stand out. HMOs keep expenses down and have lower premiums because services are obtained through a provider network that I found limiting in most cases. PPOs offer more flexibility to choose a provider and the option to obtain services from providers beyond a geographic area. Perhaps you desire to travel out of state to see a renowned specialist for your medical issue, such as I have had to do.

If this all sounds overwhelming, it can be. There is help available. The option I choose was to go through a local agent to purchase the insurance. There was no extra fee for this service and I found it was helpful to have somebody that could help me navigate the options.Insurance from the Marketplace can also be handled on your own through the Marketplace online.

You can find information about Marketplace plans at http://www.healthcare.gov. When you investigate individual plans you will see provider names you recognize such as BlueCross Blue Shield of Michigan, Priority Health, Meridian, Spectrum, Blue Care Network, McLaren and others. Once I made the HMO choice and picked a provider, I had confidence in the big decision of finding my comfort level of premium versus deductibles.

If you qualify for a subsidy and have lots of medical expense, the website states that a plan in the Silver category provides not only a premium subsidy, but other savings including deductibles, copayments and coinsurance.Investigate all your options carefully because for every generality mentioned here there are specific rules and exceptions for each provider. This writer’s advice is to stay healthy. Take advantage of regular exercise, eating well and good living to help avoid being a high-end consumer of medical services.

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