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Heatlh professional handing insurance card to patient.
There are some very good reasons for people who have their health insurance through Obamacare to not just auto-enroll in their same plans again. The biggest reason is potential premium sticker shock as the marketplace brings on new insurance companies and rates—and the subsidies 85 percent of Obamacare customers receive—are adjusted. But looking at all the available options is smart for everyone as open enrollment season opens, because the health insurance world is changing pretty regularly and rapidly these days.

Larry Levitt of the Kaiser Family Foundation helped walk listeners of California's KPCC radio through all the baffling terminology, and what's hidden behind those acronyms and how to figure it all out.

The first thing, he says, is to not give in to your first instinct to ignore it all and just let stay in your current plan.

"There are lots of reasons to shop around, particularly this year," he says. […]

"Some plans are increasing premiums, some plans are decreasing premiums," he says. "So you could find yourself saving a lot of money if you switch plans."

But it's a lot easier to want to wade into shopping for health insurance—even among your employer-sponsored plans—if you know what in the hell they're talking about with their PPOs, EPOs and HMOs. Those are the three main types of policies you'll probably be seeing. Within those categories, you'll also see POSs and HDHPs. To wade through what all of this means, head below the fold.

EPO stands for "exclusive provider organization." These are plans that have very narrow provider networks—that means that they contract with just a handful of doctors, labs, or hospitals, and that someone on one of these plans will only be covered if they see go to these providers. But the advantage of an EPO is of use for the patient within those networks. For example, there aren't gatekeepers—you don't need a referral from a general practitioner to see a specialist. But if you see someone outside the EPO network, you have to pay 100 percent of the bill.

PPOs are "preferred provider organizations." They've traditionally been the most flexible (and most expensive) plans, with large provider networks and fairly generous coverage for care even outside of the network. But in some states lately, PPO plans have been getting narrower in order for companies to save money. That can cause real problems for someone with a PPO plan who goes to a regular provider only to learn afterward that that doctor isn't in their network anymore. It's happened.

Business owner Pamela Robins experienced a similar problem. It was only after undergoing expensive surgery to repair a broken collar bone, that her providers realized they weren't part of her Los Angeles area Blue Shield PPO.

"I went into admissions, I gave them my card, I was accepted for surgery that day and I had the surgery," she says. "And then I got a bill for $76,000."

If you have a PPO plan and want to stick with it, double check with providers and with the insurance company to make sure that the doctors you want to see are still in the plan. It's another good reason to use the open enrollment period to make sure your insurance plan still fits. It's sort of like checking your smoke detector batteries when resetting your clocks twice a year—use this as an opportunity to make sure you're going to be covered the way you want to be next year.

The final category of plan is the least flexible. That's HMOs, or health maintenance organizations. HMOs are comprehensive systems, with doctors, labs, hospitals and pharmacies all within the same system within which you have to stay to have your care covered. HMOs require a primary care doctor acting as a gatekeeper, providing referrals for every service. But no matter who you see, your visit is going to be covered, so an HMO provides certainty. They're also often the least expensive option—a closed and integrated network is easy and cheap to administer, so costs are easier to control and that trickles down to the patient.

But that's not all! There are other plans, like POSs—point of service plans. They function much like PPOs, in which you can see any provider within the network without a referral, but have to have one to to see an out-of-network doctor. There are also HDHPs, high deductible health plans, that have low premiums but high deductibles. These lower-premium, higher-deductible plans allow HSAs—health savings accounts. Those are savings accounts dedicated just for medical expenses, to help cover the stuff you have to pay for out-of-pocket (OOP, if you're feeling alphabet happy by now). HSAs are not subject to federal taxes, and can roll over year to year. There are also FSAs—flexible savings accounts, which function sort of the same but are use-it-or-lose-it. You can't roll them over year to year.

To make it even more fun, some insurers (like Blue Cross and Blue Shield) have things like CDHP, or consumer directed health plans, which are like HDHPs, but apparently "consumer directed" sounds better than "high deductible."

Finally, even within all of these types of plans, there are different options. Obamacare and the exchanges call them Gold, Silver, and Bronze, but they'll go by different monikers depending on your insurance. For example, I'm offered through Blue Shield of California a whole bunch of PPOs like PPO500, PPO750, PPO5000, etc. The difference among these is how much of a deductible you'll have to pay and what your out-of-pocket limits will be.(Obamacare limits out-of-pocket expenses to $6,350 for an individual plan and $12,700 for a family plan.) The plans with lower deductibles and other costs generally have higher premiums, but that's not all. It's worth reading the synopsis provided by your provider of what all is covered, partially covered, or not covered in each plan.

It's eye-glazing stuff, but if you know some of these basics going into the process, it takes away one layer of incomprehensibility. Going through the process is certainly worth your time. You could save yourself some unwelcome and expensive surprises in the event of an accident or illness, or even just some money on monthly premiums.

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Comment Preferences

  •  Please keep the information coming (24+ / 0-)

    A lot of people still in the dark; unfortunately, it's probably going to be up to this site and membership to keep people on the cutting edge.

    Cudos

  •  Health insurance is a bureaucratic maze (21+ / 0-)

    I cannot imagine trying to explain it to someone who never had insurance before or worse someone who doesn't speak English.

    Single payer is the only way to go. Even in Switzerland they get it.

    Daily Kos an oasis of truth. Truth that leads to action. UID: 9742

    by Shockwave on Sun Aug 17, 2014 at 02:58:23 PM PDT

  •  well we are not having these problems (10+ / 0-)

    the difficulties we are experiencing in VA is:

    only policies offered are high deductible with the lowest premium (not subsidized) at 500 a month and then the insurance company won't pay a dime until you hit the high deductible (like 5-12k) - people all over are balking at paying those premiums while the insurance company pays nothing towards the bills - which means we have to have 5-12k in our pocket - which we don't.

    I am not subsidized because (besides the stupidity of our previous governor) I am tied to income levels from earlier this year which I no longer have or have access to - seems my CURRENT income would be much more important but no - the policy is calculated on what i USED to make.  

    So the premium is too high.    See last year I got sick - really sick - and so when I had to retire because of it I also had to stay on cobra which is SO expensive but has a low deductable.   Unfortunately the premium sucks the money out of the house so we have no money left over to insure anyone else in the family.   My medical bills last year was over 200k so I need to stay on my policy which leaves the rest of the fam keeping their fingers crossed that they won't get sick.

    any kind of health care here cost a bundle - routine care is so expensive - the slightest medical attention - sprained wrist?  2k right there.    The legislation has done NOTHING  towards cost.   So the captive audience (we have only one hospital and one insurance providor anthem) can charge ANYTHING.

    obamacare is far from perfect - I know all the excuses but we went from insured (all of us) to half insured because we cannot afford to spend half our income in premiums to anthem.

    we need cost control on the hospital and insurer level
    we need more vendors so there is more competition
    we need the medicaid expansion
    and we need to be tied to current income not past income
    we need PPO too - no just HD choices

    my two cents
     

  •  Was looking forward to this one, Joan. (9+ / 0-)

    This "confusion" is pretty much what all the PPACA stories are about these day. As if it was President Obama who created the unreadable crap that has plagued the health insurance industry policy maze for all these years.



    For an idea that does not at first seem insane, there is no hope.
    - Albert Einstein:  Leftist, socialist, emo-prog, cosmic visionary.

    by Pluto on Sun Aug 17, 2014 at 03:30:53 PM PDT

    •  Obama didn't create all that red tape and un- (4+ / 0-)
      Recommended by:
      kerplunk, ladybug53, Pluto, Audri

      -readable crap, but it was fairly predictable the way "Obamacare" was set up.  One GOOD thing they did is that the policies are standardized.  They have letters A through H, I think, and Blue Cross's Silver F policy should be identical to Humana's Silver F policy.  That's helpful.  I hope next year's F policy will have the exact same coverage as this year's.  

      Single payer would have been a whole lot simpler.  Putting everyone on Medicare would have been about like putting everyone on 80% single payer, which is a bit more complicated, but people would have had a good idea what to expect.

      We're all pretty strange one way or another; some of us just hide it better. "Normal" is a dryer setting.

      by david78209 on Sun Aug 17, 2014 at 04:33:03 PM PDT

      [ Parent ]

      •  I Say It Was That Idiot Max Baucus And Gramma (7+ / 0-)

        Grassley that let the insurance lobby come in and put all these distractions and maze of insurance and medical loopholes to confound and confuse all consumers.

        All to allow the insurance companies to contest all claims because the rules and loopholes are such a maze few know what IS allowed and the consumer is left to fight on their own.

        The insurance companies are in the driver seat.  They send your claim back and say they aren't paying it.  In the mean time if you don't pay it out of pocket, you get sent to collections and your credit rating is ruined.  The system is set up to defraud the consumer with ease.

        "I think that gay marriage is something that should be between a man and a woman.” - Arnold Schwarzenegger 2003

        by kerplunk on Sun Aug 17, 2014 at 05:05:23 PM PDT

        [ Parent ]

  •  Having dealt with the maze that is the HSA (6+ / 0-)

    type plan, I think the main beneficiaries of them are the banks.

    Fry, don't be a hero! It's not covered by our health plan!

    by elfling on Sun Aug 17, 2014 at 03:35:13 PM PDT

    •  Yes It Can Be Messed Up (1+ / 0-)
      Recommended by:
      ladybug53

      The often poor choices of investments offered, the fees on the investments, the fees charged by the bank or brokerage, the various fees to move this or that.  Some cases you are forced into who the employer chose as the HSA custodian.  

      "I think that gay marriage is something that should be between a man and a woman.” - Arnold Schwarzenegger 2003

      by kerplunk on Sun Aug 17, 2014 at 04:58:14 PM PDT

      [ Parent ]

    •  I found the system incredibly frustrating, and ... (0+ / 0-)

      I found the system incredibly frustrating, and I think the only advantage to them is if someone else is fully funding the HSA account in January for you. But having looked at all the various costs, I think the total cost of these plans is higher than a regular plan - it's just the taxpayer subsidy that makes them somewhat more affordable to the consumer, maybe.

  •  Not all POS plans require referrals (8+ / 0-)

    I've had one for the last 20 years that has not required referrals at all.  In network has a small copay and no deductible.  Out of network has a deductible after which the insurance company pays a percentage.  That is the difference between in and out of network for my coverage.

    What bugs me (though I believe this has been fixed) is when one goes to an in network facility for surgery with an in network surgeon only to receive a large bill for the anesthesiologist who was out of network.  How are we supposed to pick our anesthesiologist?  I fought the company on that and they ended up covering it in network.  What a pain!

    “It is the job of the artist to think outside the boundaries of permissible thought and dare say things that no one else will say."—Howard Zinn

    by musiclady on Sun Aug 17, 2014 at 03:42:43 PM PDT

    •  Is that an employer plan? (1+ / 0-)
      Recommended by:
      ladybug53

      It sounds pretty good.



      For an idea that does not at first seem insane, there is no hope.
      - Albert Einstein:  Leftist, socialist, emo-prog, cosmic visionary.

      by Pluto on Sun Aug 17, 2014 at 03:52:28 PM PDT

      [ Parent ]

      •  Yes. It's excellent. (2+ / 0-)
        Recommended by:
        Pluto, ladybug53

        In network--$15 copay for primary care doc, $20 for specialists.  All hospital expenses covered.  $100 copay for ER if not admitted.  I paid $10 for hand surgery a few years ago.
        Out of network has a $300 deductible ($600 for family) and they pay 80% after that.

        In network diagnostic stuff has no copay.  It is excellent.  Sometimes we forget.  Our copays were $10 and were raised last year.  You should've heard everyone complain!

        “It is the job of the artist to think outside the boundaries of permissible thought and dare say things that no one else will say."—Howard Zinn

        by musiclady on Sun Aug 17, 2014 at 04:05:24 PM PDT

        [ Parent ]

    •  Almost all anaesthesiologists (1+ / 0-)
      Recommended by:
      Shaylors Provence

      are out of network.  But don't try major surgery without one.

      Democrats give you the Bill of Rights; Republicans sell you a bill of goods!

      by barbwires on Sun Aug 17, 2014 at 05:20:17 PM PDT

      [ Parent ]

  •  I will have to switch plans. (4+ / 0-)
    Recommended by:
    Pluto, david78209, kerplunk, ladybug53

    I will not be getting a subsidy because my income went over the line this year due to a single fee paid for a single lawsuit.
    I will have no choice but to find something with a cheaper premium, and hope it will cover essentials until I can get on Medicare in 3 years.
    At the very least, if I stick with BCBS of Texas, I will go to the bronze plan, forego the silver plan I now have.

    •  Go Kaiser HMO (2+ / 0-)
      Recommended by:
      ladybug53, on the cusp

      It is available in some parts of Texas.

    •  There Are Some Ways You Can Lower Your (6+ / 0-)

      reported income and possibly still qualify for the subsidy.  If you can reduce your Obamacare MAGI (modified adjusted gross income) you may fall below the subsidy cut off point.  One way is to use an HDHP insurance policy with an HSA.  You can reduce your MAGI by $4300 by contributing that amount to your HSA account and then deducting it "above the line" on your IRS income tax return.  This will reduce your MAGI and may qualify you for the subsidy.  Another way is to contribute to an IRA which also reduces your income 'above the line" on IRS form.

      "I think that gay marriage is something that should be between a man and a woman.” - Arnold Schwarzenegger 2003

      by kerplunk on Sun Aug 17, 2014 at 04:48:04 PM PDT

      [ Parent ]

  •  I walked several family through the Medicare (4+ / 0-)
    Recommended by:
    on the cusp, ladybug53, annan, splashy

    …process a couple of years ago -- which means I had to learn it from scratch. (I was almost tempted to write a how-to book about it, at that point.)

    In any event, it is a utopian dream (or has been for my lab rats).

    With Medicare and a Plan G supplement (never Medicare advantage with is a crippling scam) and a clever algorithm to select the perfect Plan D (which has to change each year, because it's also a scam where they start gouging the elderly in year two) -- it is a total breeze.

    No big bills and the government keeps an eye on it. If you call Medicare about a charge, they eye it as fraud -- so they are totally on your side.

    There's not much to think about. And all the doctors and hospitals take Medicare. No networks (unless you buy one of the horrible Medicare advantage plans) to worry about. Fantastic care and they follow up like crazy because hospitals are not paid if there is a readmission. (Thank you Obama, for that.)

    Plus, very low premiums because it is single payer and non-profit.



    For an idea that does not at first seem insane, there is no hope.
    - Albert Einstein:  Leftist, socialist, emo-prog, cosmic visionary.

    by Pluto on Sun Aug 17, 2014 at 03:50:00 PM PDT

    •  Some errors in that: (2+ / 0-)
      Recommended by:
      ladybug53, Shaylors Provence
      And all the doctors and hospitals take Medicare.
       Not
      (never Medicare advantage with is a crippling scam)
      Not

      That, in its essence, is fascism--ownership of government by an individual, by a group, or by any other controlling private power. -- Franklin D. Roosevelt --

      by enhydra lutris on Sun Aug 17, 2014 at 05:07:40 PM PDT

      [ Parent ]

      •  Well, those were the findings for the (0+ / 0-)

        …large city where I did my research. Naturally, other cities may differ.

        President Obama tried to get rid of Medicare Advantage, and I fully supported that after what I had seen and learned. People on Medicare alone had much better outcomes. And, of course, with a Medicare Supplement policy, they were way ahead, almost at VIP level. One can even use Medicare in foreign countries with a supplement.

        But he was forced to back down to funnel graft to the insurance companies.



        For an idea that does not at first seem insane, there is no hope.
        - Albert Einstein:  Leftist, socialist, emo-prog, cosmic visionary.

        by Pluto on Sun Aug 17, 2014 at 05:43:03 PM PDT

        [ Parent ]

  •  What happens if you move from one state (2+ / 0-)
    Recommended by:
    ladybug53, annan

    to another? How long will my CA insurance cover me in Nevada? I just have to wait 'til the new open enrollment?

    "Gussie, a glutton for punishment, stared at himself in the mirror."

    by GussieFN on Sun Aug 17, 2014 at 03:59:49 PM PDT

  •  Not Always True. (4+ / 0-)
    But no matter who you see, your visit is going to be covered, so an HMO provides certainty.
    My HMO referred me to one of their contracted providers and the provider billed me for the cost of a colonoscopy which according to the HMO policy and Obamacare should have been free as a preventative procedure.

    I was told by the HMO customer service (after the fact) that if I had had the procedure done within the HMO facility it would have been covered or have a better case for having it reduced.

    When they referred me to one of their contract providers I had no idea it was not considered part of the HMO.

    I would recommend calling the HMO customer service before having any procedure and ask them what is covered.  I would try to get it in writing.  Of course the answer you get will depend on how you asked the question and if you aren't into the medical lingo or know of all the potential pitfalls  you may be told one thing and then find out later you didn't ask the right questions  and pay the price.

    Also as another warning in all cases and all policy types is that almost always the deductible does not count when going out of your network of providers.  You pay the whole bill from the out of network provider.  It does not go toward your deductible.  You may find that your surgeon is indeed in your network, however the anesthesiologist or the special nurse or the surgery cleanup person may not be in your network and you will be charged full price for their service.  How are you suppose to know as a lay person who will be needed during your surgery let alone whether or not they are a network covered provider?  You don't, you simply find out after the surgery that all these non covered people worked on you and you pay the prices.  You could question your surgeon who are the assistance that will be used and find out if they are in the network, but who would even know how to ask the right questions to get a full answer?  Apparently some providers who are directly contracted by the HMO are supposedly covered but that provider might contract with a different provider for some service and those providers are not in the network so you pay full price.  It's a sick process.

    It is maddening to realize that a layperson has to investigate and figure this all out and not knowing can cost tens of thousands of dollars quickly.

    "I think that gay marriage is something that should be between a man and a woman.” - Arnold Schwarzenegger 2003

    by kerplunk on Sun Aug 17, 2014 at 04:30:57 PM PDT

  •  Also Another Warning Is That Some Policys (3+ / 0-)
    Recommended by:
    ladybug53, BlueMississippi, Audri

    refer to themselves as "high deductible" but don't qualify as a real HDHP/CDHP policy.  To be a true HDHP/CDHP policy and be qualified to allow use of an HSA the deductible amount has to be at least a certain amount and the out of pocket amount has to be at least a certain amount.  These certain amounts are set by the IRS I think and change annually.

    "I think that gay marriage is something that should be between a man and a woman.” - Arnold Schwarzenegger 2003

    by kerplunk on Sun Aug 17, 2014 at 04:37:26 PM PDT

    •  Oh, Need To Also Say That If The Policy Allows (2+ / 0-)
      Recommended by:
      ladybug53, Audri

      any co-pay before the deductible is met, it does not qualify as a real HDHP/CDHP policy that can be used with an HSA.

      "I think that gay marriage is something that should be between a man and a woman.” - Arnold Schwarzenegger 2003

      by kerplunk on Sun Aug 17, 2014 at 04:40:17 PM PDT

      [ Parent ]

  •  Some HMOs. like Kaiser Permanente, do (2+ / 0-)
    Recommended by:
    ladybug53, barbwires

    cover services outside of the area if the need is urgent and you are not near one of their facilities.

    That, in its essence, is fascism--ownership of government by an individual, by a group, or by any other controlling private power. -- Franklin D. Roosevelt --

    by enhydra lutris on Sun Aug 17, 2014 at 05:00:01 PM PDT

  •  It's time (3+ / 0-)
    Recommended by:
    BlueMississippi, GayHillbilly, Audri

    to stop all of this bureaucratic malarkey that gets patients caught in the middle and paying as much out-of-pocket costs as they used to while still paying insurance premiums.  Deductibles, co-pays, exclusive networks, and balance billing have to go.

    Democrats had the chance to fix this and they sold out (thanks Max Baucus, Evan Bayh).

    50 states, 210 media market, 435 Congressional Districts, 3080 counties, 192,480 precincts

    by TarheelDem on Sun Aug 17, 2014 at 05:54:27 PM PDT

  •  I love these ACA diaries ... with one essential (3+ / 0-)

    caveat: every state's implementation is different due to the quirks of the various (ha! just typed avarice) state insurance commissions.

    These basic ABC's apply across state lines, but the devil is in the details. Buyer beware.

    "Let us not look back to the past with anger, nor towards the future with fear, but look around with awareness." James Thurber

    by annan on Sun Aug 17, 2014 at 06:09:55 PM PDT

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