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6 health insurance terms you need to know as open enrollment begins

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It's open enrollment season, the time each year when millions of American workers and retirees must choose a health plan, whether new or existing.

But picking health insurance can be a dizzying venture. Health plans have many moving parts — which may not come into focus at first glance. And each has financial implications for buyers.

"It is confusing, and people have no idea how much they could potentially have to pay," said Carolyn McClanahan, a certified financial planner and founder of Life Planning Partners, based in Jacksonville, Florida. She is also a medical doctor.

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Making a mistake can be costly; consumers are generally locked into their health insurance for a year, with limited exception.

Here's a guide to the major cost components of health insurance and how they may impact your bill.

1. Premiums

The premium is the sum you pay an insurer each month to participate in the health plan.

It's perhaps the most transparent and easy-to-understand cost component of a health plan — the equivalent of a sticker price.

The average premium for an individual is $7,911 a year — or $659 a month — in 2022, according to a report on employer coverage from the Kaiser Family Foundation, a nonprofit. It's $22,463 a year — $1,872 a month — for family coverage.

However, employers often pay a share of these premiums for their workers, greatly reducing the cost. The average worker pays a total $1,327 per year — or, $111 a month — for individual coverage and $6,106 — $509 a month — for family coverage in 2022, after factoring in employers' share.

Your monthly payment may be higher or lower depending on the type of plan you choose, the size of your employer, your geography and other factors, according to KFF.

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Low premiums don't necessarily translate to good value. You may be on the hook for a big bill later if you see a doctor or pay for a procedure, depending on the plan.

"When you're shopping for health insurance, people naturally shop like they do for most products — by the price," said Karen Pollitz, co-director of KFF's program on patient and consumer protections.

"If you're shopping for tennis shoes or rice, you know what you're getting" for the price, she said. "But people really should not just price shop, because health insurance is not a commodity.

"The plans can be quite different" from each other, she added.

2. Co-pay

3. Co-insurance

4. Deductible

5. Out-of-pocket maximum

Most people also have an "out-of-pocket maximum."

This is a limit on the total cost sharing consumers pay during the year — including co-pays, co-insurance and deductibles.

"The insurer can't ask you for a co-pay at the doctor or pharmacy, or hit you for more deductibles," Pollitz said. "That's it; you've given your pound of flesh."

More than 99% of workers with single coverage are in a plan with an out-of-pocket maximum, according to KFF.

And the range can be large: 8% of workers with single coverage have an out-of-pocket maximum of less than $2,000, but 26% have one of $6,000 or more, according to KFF data.

Out-of-pocket maximums for health plans purchased through an Affordable Care Act marketplace can't exceed $9,100 for individuals or $18,200 for a family in 2023.

6. Network

How to bundle it all together

"Understand the first dollars and the potential last dollars when picking your insurance," McClanahan said, referring to upfront premiums and back-end cost-sharing.

Every health plan has a "summary of benefits and coverage," which presents key cost-sharing information and plan details uniformly across all health insurance, Pollitz said.

"I'd urge people to spend a little time with the SBC," she said. "Don't wait until an hour before the deadline to take a look. The stakes are high."

Further, if you're currently using a doctor or network of providers you like, ensure those providers are covered under your new insurance plan if you intend to switch, McClanahan said. You can consult an insurer's in-network online directory or call your doctor or provider to ask if they accept your new insurance.

The same rationale goes for prescription drugs, Sun said: Would the cost of your current prescriptions change under a new health plan?

Source: https://www.cnbc.com/2022/11/06/health-insurance-terms-to-learn-as-open-enrollment-begins.html


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