The information you need for tackling open enrollment
The Affordable Care Act (ACA), Obamacare, the individual health-care mandate, health savings accounts, high deductibles — how in the world are you supposed to find the best health insurance companies? Unfortunately, picking a top health insurance company isn’t as straightforward as finding a low rate on car insurance, for instance. The best company and plan for you will vary tremendously based on the level of coverage you want, your budget, and your location. In fact, where you live may severely limit your choices.
Finding a Top Health Insurance Plan in Your Area
Enter Your Zip Code:
Because there is no “best” health insurance company for most people, I’ll instead focus on finding the best provider and plan for you. I’ll discuss how geography affects your choice of health insurance and briefly mention companies that have a reputation for customer satisfaction. I’ll also cover how different types of health plans operate, what major medical plans must include, and special considerations that may apply when you’re shopping. For an in-depth discussion on how to find a good plan on a budget, check out my post on How to Find Affordable Health Insurance in 2014.
How Geography Affects Your Health Insurance Choices
The reality of the U.S. health insurance industry means you may not have much latitude to choose your provider. How much choice you have almost entirely depends on where you live. Generally, if you’re in a big city in a densely populated state, a good number of insurers will be competing for your business. But in some rural areas, there may be a single dominant insurer. In fact, in 2010, a single insurer had gobbled up more than half the market for individual health care plans in 30 states, according to the Kaiser Family Foundation.
For example, if I lived in New York City and needed individual medical coverage, I could choose from more than 150 plans from at least a dozen health insurance companies on that state’s health insurance exchange. If I lived in Wheeling, W. Va. I could choose from 14 plans on the federal health exchange (used by many states, including West Virginia), all provided by a single insurer: Blue Cross Blue Shield.
Though the ACA aims to stimulate more competition across the country, so far, results have been mixed. Experts are cautiously optimistic that consumers will have more choices as more insurers throw their hats into the ring. But for now, in some parts of the country, the best health insurance company for you may be the only one that will take your business.
Best Health Insurance Companies for Customer Satisfaction
If you’re lucky enough to live in an area with a lot of top health insurance companies offering competitively priced plans, you may be able to factor in an insurer’s reputation for providing satisfactory service. Be careful not to put too much stock in individual reviews of health-care companies, however. They are highly dependent on very personal circumstances, and they are overwhelmingly negative across the board.
There are a few resources that allow you to get a wider, more reliable snapshot of the top health insurance companies. J.D. Power’s 2014 Member Health Plan Study ranks several providers by U.S. region. Insurers who come out at or near the top in several states include the Kaiser Foundation Health Plan, Blue Cross Blue Shield, Aetna, and Cigna. (Be sure to check your specific region, as the same insurers that are in the top in some states may rank at the bottom in other states.)
In Insure.com’s 2014 customer satisfaction ratings, Kaiser Permanente (parent company of Kaiser Foundation Health Plan) comes out on top, followed by Humana, Blue Cross and Blue Shield of Florida, and UnitedHealthcare.
You may also obtain rankings for certain plans via Consumer Reports, which obtains data from the National Committee for Quality Assurance. You can search for plans in your area by selecting plan type (HMO, PPO, Medicare, or Medicaid) and state.
Finding the Best Health Insurance for You
If you’re in an area with limited choices or your preferred providers are too expensive, it’s still possible to zero in on a plan that will work for you, regardless of company. To do so, you’ll need to understand what types of plans are out there, what kind of coverage is already included in major medical health insurance plans, and whether you have special considerations that will affect your decision.
If your budget is the major driving force behind your decision, be sure to check out How to Find Affordable Health Insurance in 2014. You’ll find a more detailed discussion of the shopping process and how to find the most affordable plan you can without skimping on coverage.
Selecting the right plan type
One major factor to consider is the type of health care plan that makes sense for you. But keep in mind that your location will also affect how much choice you have regarding plan types, just like it does with providers.
HMOs (health management organizations) may be the most infamous type of health insurance plan. This is likely because they’re the most restrictive. With an HMO, you must receive your care within your HMO’s provider network, and you must go through your primary care physician for a referral if you need to see a specialist. If you receive care out of your network, you could be on the hook for the entire bill.
Cost management is the main goal, and pro, of going with an HMO. HMOs are more likely to charge flat copays instead of coinsurance, and you may not have to pay a deductible before your insurance kicks in. That can make HMOs a good choice if you’re on a tight budget. However, if you know you’ll need a lot of specialized care, you might find an HMO frustratingly limiting.
PPOs (preferred provider organizations) give you much more latitude to choose your health providers. You don’t need to go through a single primary care physician to receive a referral. Though you still pay less if you stay in your PPO network, you probably won’t have to pay the whole bill if you decide to go out of network. If you want to shop around for doctors or have a condition that demands specialized care, a PPO could be your best bet.
While lower costs are the main pro of an HMO, higher costs are the main con of a PPO. You’ll need to pay your deductible before your insurance kicks in, and you’ll probably pay coinsurance for certain services instead of a flat copay. If you go out of network, you may have to pay your bill upfront and then file for reimbursement, a potentially lengthy and frustrating process.
Hybrid plans: POS plans and EPOs
POS (point of service) plans aim to blend the characteristics of HMOs and PPOs. You’ll need to go through a primary care physician for referrals, much like an HMO. However, a POS plan also allows you to receive care outside your network like a PPO.
EPOs (exclusive provider organizations) are the least common plan type. They’re also a blend of PPOs and HMOs. Like HMOs, you must receive care in network. Like PPOs, you won’t need to go through your primary care physician to get a referral. However, you may need to get preauthorization for more expensive services.
Short-term health plans
the other four plans on this list, short-term health plans are not major medical plans. They are inexpensive, stop-gap plans meant to hedge against catastrophic health disasters, maybe while you’re in between jobs or because you are shopping outside of open enrollment. Your deductible will likely be very high.
The major pro here is that short-term plans are the cheapest plans you can get. But ACA regulations don’t apply to short-term health plans, which are the only ones for sale when it isn’t open enrollment. These plans are not required to provide benefits such as preventative care, and there will be a cap on benefits — this is no longer allowed for major medical plans. You may not even qualify if you have pre-existing health conditions, also prohibited for other health plans by the ACA.
Essential health benefits
One of the major requirements of the ACA is that all major medical insurance plans you can purchase as an individual (excluding short-term health insurance, discussed above) must cover a set of 10 essential health benefits. These benefits apply regardless of whether you buy your plan through a state or federal health exchange, from an insurance broker, or directly from an insurance company. They are as follows:
- Ambulatory (outpatient) care. This is care you receive on an outpatient basis — that is, without getting admitted to a hospital. It includes standard doctor’s office appointments and in-home health visits.
- Emergency care. This includes any care you receive for a potentially debilitating or fatal condition. Ambulance and emergency-room treatment are common examples.
- Hospital care. Any care you receive as a patient at a hospital or skilled nursing facility is covered. This includes lab work, surgery, medications, and any other treatment you receive as a patient.
- Laboratory services. Tests necessary to diagnose, monitor, or rule out certain conditions are covered.
- Maternal health and newborn care. This includes all prenatal care for expectant mothers, as well as labor, delivery, postnatal care, and newborn care.
- Mental health care and addiction treatment. Whether inpatient or outpatient, this includes any care necessary to diagnose, monitor, or treat mental illness or addiction. Some plans limit treatment to a certain number of days.
- Pediatric services. This includes all care provided to children, including yearly checkups, vaccinations, dental care, and vision care.
- Prescriptions. Plans must cover at least one medication in every federal category and class of prescription drugs. Insurers still have preferred-drug lists and may require generics over name-brand drugs, among other restrictions.
- Preventative care. This includes physicals, screenings, immunizations and other services meant to prevent or detect illness or other conditions, as well as the management of chronic conditions.
- Rehabilitative and habilitative care. These services help you gain or regain abilities limited or lost to or limited by injuries, illness, or other conditions. Examples might include physical therapy, occupational therapy, and speech therapy. Some plans limit treatment to a certain number of sessions a year.
Special considerations: Looking beyond essential benefits
While the list of essential health benefits seems exhaustive, there are still a number of factors that can affect your coverage depending on where you live and which provider and plan you choose. For these issues, it’s especially important to read the fine print to see what’s covered when you’re shopping for a plan.
Staying in network
If you have an existing relationship with a certain health-care provider and want to maintain it, never assume that provider will be in network on your new plan. Likewise, if you don’t want to be restricted to a small number of providers or certain hospitals, you’ll need to shop carefully. For instance, all doctors at a certain hospital (or even within a certain practice) may not be members of the same insurance networks.
Experts say many insurers are cutting costs by narrowing their provider networks. While this might be a good thing if you don’t need much care and want to save money, it increases the chances that you’ll have to pay steep out-of-pocket costs for out-of-network care.
Yes, prescription drugs must be covered under the ACA, as noted above. But there’s no guarantee that the specific drugs you take will be covered, and what you’ll pay still varies by plan.
If you take certain medications, you’ll want to check a potential plan’s preferred-drug list, or formulary, to see whether it’s covered. This information is typically available on an insurer’s website. If your drug isn’t covered, your doctor can help you request it by explaining how it’s necessary for your treatment, but the process may not be a quick one, and there are no guarantees.
If you know you’ll need prescriptions filled regularly, you’ll also want to pay attention to cost. Your plan will likely require either coinsurance or a copay for prescriptions. Coinsurance means you pay a certain percentage of each drug’s cost (around 30% is typical). If you have a copay, you’ll pay a certain fixed amount (roughly $10-$20) when you need a prescription, but it’s independent of the drug’s price. That usually makes copays a better bet if you know the drugs you take are expensive.
Mental health coverage
Again, some mental health care is required in every major medical plan. But beyond that, what kind of services are covered can vary tremendously by state. If you have a specific need, you’ll need to wade into the fine print of a plan’s benefits summary to determine whether you’ll be covered. And if you want to see a specific provider, such as a certain therapist or psychiatrist, you’ll need to make sure he or she is in your network. It’s not uncommon for psychiatrists to refuse joining insurance networks to manage high demand and combat low reimbursements compared with other services.
Rehabilitative and habilitative care
Like mental health care, rehabilitative and habilitative care is more of a gray area for insurers. Even though some coverage is required, what’s covered and the limits on that coverage will vary by state and by plan. Experts say those with chronic conditions need to pay especially close attention to the fine print. Because treatment tends to be more expensive, insurers have greater incentive to cap these benefits or skip them entirely. So while your physical therapy for a back injury may be entirely covered, speech therapy for your autistic child may not be.
Now Is the Time to Act if You Need Health Insurance
Remember, you will be shut out of major medical plans if you don’t enroll by Feb. 15, 2015. You can shop on your state’s health exchange or through insurers’ websites, quote-comparison tools like the one above, or an insurance broker if you feel you need expert guidance. However, you’ll need to enroll through the exchanges to take advantage of any tax subsidies to which you may be entitled.
The complex interplay between health insurers, health care providers, and customers makes it hard to single out the best health insurance companies. You may also be limited to a few companies (or even just one) depending on where you live. Instead of trying to find the top health insurance companies, focus on finding the best plan to fit your needs at a price you can afford. If you find a few satisfactory choices through different providers, then you can investigate the company’s reputation online and by asking family and friends — just don’t make it your primary consideration.