Enrollment: ‘Beating the clock’ isn’t enough

With just two weeks remaining before the window slams shut on the Affordable Care Act’s open enrollment period, unquestionably, the best advice for the uninsured is to run – don’t walk – to get help with the enrollment process. But once you’ve made that decision to enroll, this advice is equally critical: Avoid the huge rookie error of buying the cheapest plan available and focus on finding plans that fit your situation.

There’s not just good news and bad news. There’s very good news and very bad news.

The very good news is that – chances are – you’ll find that good coverage will cost you less than you might expect because of the availability of tax credits and subsidies to help you afford insurance. By the end of February, 4.2 million Americans had enrolled in a health plan through either a state or federal exchange and, according to the Department of Health and Human Services, more than 8 of every 10 people qualified for the financial assistance provided under the Affordable Care Act.

The federal subsidies are available to individuals with incomes up to $42,000 – and families of four up to $94,000 – but you can’t get them unless you enroll through an exchange. (This site provides a calculator that can help people determine how much financial help they might be eligible for.)

The very bad news is that if you miss the March 31 deadline, you will only be able to enroll in a plan for 2014 through an Obamacare exchange if you experience a significant life change, such as getting married or losing your job. If you remain uninsured, you may be liable for a penalty of up to 1 percent of your income.

Avoid ‘buyers’ remorse’

Enrolling in a health plan is much easier than it used to be, but it’s still not as easy as ordering a book from Amazon.com. You’ll have to plug in information about yourself (and you family, if applicable), and you’ll have to sort through what in some states can be a bewildering array of choices.

Premiums vary based on how much you’re willing to pay out of your own pocket if you get sick or injured. Platinum- and Gold-level plans have higher premiums than Silver and Bronze plans, but they cover a greater percentage of medical costs.

A lot of people undoubtedly are making decisions based only on the amount of the monthly premium and giving little consideration to what they’ll have to shell out if they have to be admitted to the hospital or undergo expensive outpatient treatment. That can prove to be a costly mistake. I’m already hearing from people who wished they had spent more time evaluating their options.

One such person is Donna Smith, a cancer survivor and executive director of Health Care for All Colorado Foundation, who told me that in retrospect, she should have called the insurance companies she was considering to figure out more precisely how much money she’d have to pay on her own if she got sick again. Sure enough, right after the first of this year when the policy she selected last fall went into effect, she was hospitalized for a week and had to undergo a series of tests.

Smith said it hadn’t occur to her that picking a Gold or Platinum level plan with a higher premium could have been better deal than the Silver Kaiser Permanente plan she opted for and that seemed to be more affordable.

After her stay in the hospital, however, she found out some limitations of her coverage that made her overall financial responsibility much higher. For one thing, hospitalization under her plan required a co-insurance payment of 30 percent. She said that if she had shopped more carefully, she would have discovered that there were other Silver plans that required a co-insurance payment for inpatient care of only 20 percent.

“In retrospect,” she said, “I needed to ask much more detailed questions about the coverage. I believe now that I would have done better with one of the Gold Kaiser plans that might have cost another $150 to $200 per month but saved me from these higher costs of getting sick.”

Plenty of help available

One of the things to keep in mind is that help is available. It’s not just you and your computer. If you are uncertain about the choices you see online, you by all means should contact one of the specially trained Obamacare navigators in your area or a licensed agent or broker.

Rachel DeGolia, a Cleveland, Ohio-based navigator, says many people who seek her help, especially people who’ve been uninsured for a long time, have a very limited understanding of how health insurance works.

“It’s a big learning curve,” she said.

One of the things she helps many people with is helping them determine if their doctor or a specific hospital is in the network of a health plan they are considering. The plans offered by many health insurers have what is referred to as “narrow networks,” meaning the list of doctors and other health care providers and facilities available to health plan enrollees can be very limited.

“The narrow networks can be a problem,” DeGolia said. “You really hate to break people up with their doctors.”

She said it’s easier to determine if a hospital is in a network than a doctor. She and her fellow navigators have access to a grid showing which hospitals are in which health plan networks. No such grid exists for doctors, however.

“We can’t figure out if doctor is in plan or not,” she said. “You either have to call the doctor or call the plan itself, and even some doctors’ staff might not even know.”

One of the things navigators cannot do by law is make specific recommendations. They can’t tell you that one plan might be a better value than any other plan. They are limited to providing education and information.

Knowing that, you might want to consider contacting a licensed insurance agent or broker – and one that belongs to the National Association of Health Underwriters (NAHU) – before making your final selection of a health plan.

As NAHU, which represents more than 100,000 health insurance professionals, points out on its website, before deciding which policy is best for you or you and your family, you need to consider a number of factors, such as the scope of what you want to cover, your degree of risk toleration, the network of medical providers available, and the monthly cost.

Unlike a navigator, a licensed agent can explain the benefits and potential shortcomings of various plans and help you pick a plan that best fits your needs. One of the reasons for making certain that the agent you talk with is a member is NAHU, by the way, is that as part of their membership, NAHU members agree to abide by a code of ethics that requires them to make health care coverage recommendations with the customer’s best interest in mind. NAHU points out that while agents receive commissions from insurance carriers, the commissions cover “not only the selling of the plan but much of the servicing required” after the sale-“so service after the sale…is just as important as the sale itself.”

Bottom line: If you still haven’t enrolled in a health plan, don’t procrastinate any longer. It might take more than a few minutes in front of your computer to find a plan that best meets your needs. And it might be in your best financial interest to contact a navigator and very possibly a licensed insurance agent or broker in your state.

Wendell Potter is the co-author of Nation on The Take: How Big Money Corrupts our Democracy and founder of Tarbell, an independent, nonprofit multimedia journalism platform dedicated to investigating the powerful forces that influence public policy.