Health insurance for a family of five can be tricky. But for the last three years, we have purchased our health insurance on “The Exchange.” My husband is employed with a small company that is not required to offer health insurance, and I am a stay at home mom, so while we both enjoy many benefits that both of our jobs offer, health insurance it not one of them. Each fall, it is part of my job description to research and find health insurance that best fits our family. This is by no means an easy task. As a matter of fact, it seems more difficult each year.
For the calendar year of 2015, I was able to find a wonderful health insurance broker to answer the thousands of questions that I had at the time. We ended up with an amazing Blue Cross Blue Shield PPO policy for our family of 5. I learned a lot from this broker during our hours of phone calls researching these policies. We finally decided on a policy that cost our family $797 each month.
For our family, that is a large amount of our monthly income. However, there are two factors that play a big role in our health care decisions each year. First, our government, in their infinite wisdom, has mandated that we have health insurance. Second, I have two kids who have auto-immune diseases, and without health insurance, we would be bankrupt in less than six-months.
As we approached the end of 2015, we received notice that BCBS would not be offering PPO policies except through business/employers any longer. We were really disheartened by this decision. This was really good health insurance. We had everything set up with all our doctors, pharmacies and labs. Additionally, it meant that we would have to go back to through the research and shopping process once again.
As with most people who have shopped for health insurance on The Exchange (this term is used by medical office staff, but is what I refer to as healthcare.gov ), I was not impressed with anything about the process. The website it’s self is frustrating and not on the top of the User Friendly Site list. None the less, I updated our family information and pulled up several policies.
What I found from the 21 policies offered to us was that BCBS was not the only company pulling out of the PPO market. There were NO PPOs on our list. Because we see so many doctors, HMO policies are not an option for us, but HMOs and EPOs were our only options. I had never even heard of an EPO before, so I was a little leery of what it could be.
Upon further research, I found that EPO stands for “Exclusive Provider Organization” plan. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside the network for care. There are no out-of-network benefits. It is a kind of hybrid between the PPO and HMO. You don’t have to get a referral to see another doctor within the network like you would with an HMO. But i f you go outside of the network you are on your own.
I can share the following steps that I processed through in my search for new health insurance for our family. I hope some of my experience will help some of you make the best choice for your family.
1. Clear the clutter
Not every policy will fit your family. Decide what fits your family’s needs.
• What can your family afford to pay in monthly premiums? On the exchange, you will have a huge range of pricing for your family. Know your budget. Many policies have the same overall benefits, but may be cheaper monthly because your deductible is really big. The opposite holds true that they may be really high monthly, but the deductible will be much less. Depending on your situation, financially and physically, you can start by deleting policies that are outside of your budget. I have found the “silver” policies to be middle of the road, but I look at them all to make sure I know what my options are.
• Do you want an HMO, EPO or PPO? Make sure you know what each of these means. This is a crucial part of selecting a plan for your family.
• What types of deductible to you want to pay? This is what is going to come out of your pocket. Sometimes it all has to be paid before any of your benefits kick in. Sometimes it calculates throughout the year. (The year my first son was diagnosed we more than met our deductible. I knew I needed a hysterectomy in the next few years, so we did it that year and only had to pay a few thousand dollars of the $74,000 surgery and hospital stay.)
• Do you need a few office visits or unlimited?
• What types of office visit co-pays work for your family? You will want to consider the copay for office visits. If you think you will have many, then lower office visit costs may be for you?
• Do you need prescription coverage?
Knowing the answer to these questions will help you narrow down the search field and focus your time on actually finding a policy that works. You can usually make these determinations by simply looking at the general descriptions in the initial listings.
2. Start dissecting each policy.
This is a tedious task, mostly because you will need to open several documents. The good news is that if you are looking at several policies from the same company, you will only have to open their documents in one of the policies because, the bones of the policies are generally all the same. For example, if I have 2 policies from Aetna, all of their documents are going to be the same.
• Are your Doctors on this policy? I am a pretty organized gal, so I make a list of all of our doctors – general, pediatrician, dermatologist, gynecologist, hospital of preference, breast exams, labs, etc. – and verify everyone I am not willing to give up is covered by each company.
• Review Summary of Benefits Document. This tells you what is covered and what is not. If you know that your family is typically heavy in one area (I have 3 very active boys, so emergency room visits, for example) then make sure you have a clear understanding of what is covered and when. Do you have to meet your deductible first? Is the event fully covered or is there a co-pay? Is there a split, such as they pay 70% and you pay 30%?
• Are your prescriptions covered? This is a huge essential for us. If you don’t use many prescriptions, it may not be a big deal. My two kids with the auto-immune disease take weekly injections that keep them able to walk. Without insurance, the drug would cost $3,200 per month, per child. Obviously, this drug being covered is essential. I keep a running list of all the prescriptions we are all on and I am able to look at each companies list of covered meds. The Summary of Benefits tells you how much each “Tier” drug will cost you. Tier is just a fancy term for level 1, level 2, level 3, level 4 and level 5.
Whatever your BIG medical need is, I would advise you to do your research on this part. Call the companies and ask questions. Honestly, your family deserves the best coverage you can get for the money, and you may spend a lot of time on this part, but in the end it will prove to be well worth it.
3. Calculate it out.
Once you have your policies narrowed down to two or three that work with your doctors, cover your procedures and will pay for your prescriptions, calculate out what your year looked like this year. These examples are not all encompassing, but are intended to help you get your brain thinking about things and how to break it down.
• Let’s say you have a two of small kids and you may have been at the doctor 12 times with each one. Half of that time you many have needed a prescription. And they had a couple of x-rays because you were worried about one of them having Pneumonia.
• On Plan 1 you have $20 office visits, $15 generic prescriptions and a 30% co-pay on x-rays. We will say that the x-rays cost you $110 each just for grins.
o Office Visits – $20×24= $480
o RX – $15×12= $180
o X-rays – $110×2= $220
o Monthly premium – $557×12= $6,684
o Annual Total = $7,564
• On Plan 2 you have $5 office visits, $4 generic prescriptions and the same 30% co-pay on x-rays
o Office Visits – $5×24= $120
o Rx – $4×12= $48
o X-rays – $110×2= $220
o Monthly premium – $680×12= $8,160
o Annual total = $8,548
You will have to figure out for yourself is the actual cost difference is worth it. Sometimes it is a lot easier to spend just a little all month long and have just one bigger bill. In most cases, the differences will be greater and the decision will be much more obvious according to your family’s needs. When I think I have made a decision, I go over it with my mom or my husband. It helps to talk it out with someone and make sure you are not forgetting something important.
4. Pull the trigger
Once you have a decision you will want to enroll. The system will ask you for your first month’s premium. I’ll be honest; we were paying $797 last year with BCBS, and enrolled with Aetna for $577 a month for 2016. In December, as we prepared for Christmas, we did not have an extra $577 to send the new company.
I did start receiving letters stating that we had until late January to make the first payment and secure the policy. I also received a couple of reminder calls to pay our premium. After receiving the 2nd or 3rd recorded call from Aetna, I called them to find out what was going on. Keep in mind, all this was going on between the 1st and the 8th of January when we made our first premium payment.
It does seem like it is all about the money from the get-go with Aetna. They contacted us numerous times from the 1st to the 8th. When I made my payment on the 8th, I was told that there was no policy number for me yet and that it would take about a week to generate and I could possibly call in 72 hours to have a policy number expedited. Basically, what they were saying is that until I had made payment they were not doing squat, and then I needed to wait on them. Yes, my coverage started on the first, but if I needed to use my policy before Aetna got around to everything I would have to pay out of pocket and jump through their hoops of filing it myself.
It is a lot of work to decide on the correct health insurance for your family. It is even more work to change insurance companies altogether. However, I think that is what most companies count on. BCBS had our “new” policy cards in our hands prior to the end of the year. They were graciously changing us to an HMO – same price, but much less convenient for us. Honestly, this whole process was a beating and took me several days to digest. I am not looking forward to the process again in 11 months, but it is a necessary evil.