Where should someone go to enroll for health coverage?
If they’re employed, they can go to their human resources department during open enrollment. Those who are not working or do not qualify for other plans can visit Covered California (www.coveredca.com).
What is the best way to evaluate the available health plans?
Do a side-by-side comparison. A lot of employers offer HMO and PPO plans. With an HMO, you’re assigned to a medical group, and your primary care provider refers you to specialists. If you go outside of the network, your services may not be covered. With a PPO, you can go to any doctor, as long as they’re in the network. But they have deductibles and higher coinsurance rates — so higher out-of-pocket costs.
If someone is pregnant, has a chronic condition, or otherwise needs ongoing care, what type of plan is best?
Consider a plan that pays a higher percentage of your costs — maybe 90 percent as opposed to 30 percent. Your monthly premium may be higher, but the coverage will also be higher, so overall, you’ll pay less out of pocket.
If you’re fairly healthy and don’t think you’ll spend more than $5,000 in a year, you might choose a plan with a higher deductible.
What should people with families consider when choosing a health plan?
Make sure that each member of your family is covered. With a PPO, if the parents and children have a different physician, and they’re going to seek coverage at a hospital like ours, they need to make sure that their providers have privileges here. And if a woman is going to deliver, she needs to make sure — before her due date — that her doctor has privileges.
How can someone make sure that they’ll be able to visit their favorite doctor or hospital?
Every health plan has a list of the physicians and hospitals that are covered under the plan. We also suggest that the patient contact the provider directly, in case the lists online are not updated.
Before open enrollment, contact the provider or check their website to see if they still accept those insurances. If not, you can still visit them, but you’ll pay higher out-of-pocket costs.
EL CAMINO HOSPITAL: Financial counselors can discuss estimates for procedures and insurances that the hospital accepts. Call 650-988-8275 or visit the Self-Service Portal and Price Estimator Tool on our website.
MEDICARE: Older residents of Santa Clara County can learn about Medicare coverage from a HICAP (Health Insurance Counseling & Advocacy Program) counselor. Please call 650-940-7210 to schedule an appointment at El Camino Hospital’s Health Library & Resource Center.
COVERED CALIFORNIA: Enrollment counselors can help you choose a plan. (www.coveredca.com/support/).
This article first appeared in the Fall 2015 edition of the El Camino Hospital Health Beat magazine.