ObamaCare - The Factors that Drive Premiums
by Robert C. Intelisano
Apr 12, 2016 | 7368 views | 0 0 comments | 96 96 recommendations | email to a friend | print
By the time you’re reading this article, the enrollment window for “Obamacare” will have closed and the administration will surely be telling us how wonderful things are going.

By hiring navigators that are not licensed and cutting broker compensation by a staggering 80 percent, it’s clear to me is they are trying to phase out brokers. This leaves the public vulnerable and on their own to solve the health insurance puzzle and whether or not to go into the exchange.

It’s important for readers to understand how these policies work, as many brokers are either exiting the business or not accepting new health insurance clients anymore.

The initial factor that drives premiums is the insurance company that you choose. Be careful with this, as there are several new insurance companies that have entered the marketplace. These companies have no track record.

Tip 1: Don’t buy strictly on price, as many of these new carriers are using very limited doctor networks. The price might be attractive, but if your primary care physician doesn’t accept that plan (in-network) you will have to change doctors or foot the whole bill yourself.

Tip 2: Contact all of your preferred doctors and ask them which companies they are in-network with and which networks they accept. For example, Oxford has three networks so you need to specify which one(s) your doctor takes before changing plans.

The second factor is the type of plan. Will it be in-network only or an in and out of network plan? Going with an in-network only plan (also known as EPO or HMO) can save you as much as 20 to 40 percent on your monthly premiums.

Tip 3: Take note that the in and out of network plans (also known as PPO’s or POS plans) have changed the way they reimburse for out-of-network usage. These subtle reductions can drop your reimbursement amounts to under 50 percent, so be sure to ask for a “summary of benefits” before buying these pricey plans.

The third factor is the plan design. This takes into account variables such as office co-pay, hospital co-pay, drug card, deductibles and co-insurance amounts. The higher the co-pay, the lower your monthly premiums.

Tip 4: Use a broker to help decipher how to read the spreadsheets and to help find the “sweet spot” where the premiums are the most reasonable. Insist the broker shop the market every year.

The price will be the same so why do it yourself? Unlike the banking system and stock market, the insurance industry is regulated by individual states that decide the premiums.

Tip 5: People ask me “Robert, when would it make sense to go onto the exchange?” If you earn less than $46,000 as an individual or $94,000 as a family of four and are willing to leave your doctors, then take about 40 minutes with your tax return, fill out your profile and see if you qualify for free/subsidized coverage. If not, then you will do better off in the exchange.

Some positives on the new Obamacare plans are that pre-existing conditions are covered, kids can stay on their parents’ policies until age 26 (age 29 with the purchase of a rider), and many plans include dental and vision options.

Keep in mind that these benefits incur a cost and it may make sense to keep your pre-Obama care plan should you still have access to it.

Robert C. Intelisano is an insurance broker with Intelisano & Associates in Forest Hills. Contact him with your insurance questions at robcintel@aol.com.

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