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Tuesday, December 8, 2015

Questions to Help Health Care Consumers Choose the Right Marketplace Plan

Jessica Kendall

Director of State Partnerships

We all know that if you ask the wrong questions, you’ll get the wrong answers. And nowhere is this more important than in the health insurance marketplace, as consumers make decisions about which health plan to buy or renew. Today’s blog reviews the most important questions for assisters to ask consumers to help them choose the plan that reflects their unique health care priorities. 

Here are the top questions assisters can ask uninsured consumers and those renewing their health coverage.

Helping consumers who are renewing their coverage

In this open enrollment period, consumers currently enrolled in marketplace plans will generally be auto-enrolled (in their 2015 marketplace plan or a similar plan, with financial assistance based on the most recent income information the marketplace has available). However, it is important that consumers understand that their current plan may change significantly in 2016—it may have a different monthly premium, different providers in-network, or different deductibles or copayment amounts for some services. 

Moreover, there may be different plans available in the marketplace than there were last year. In many states, consumers will have more choices. While automatically renewing is the easier option, consumers may find that the plan they chose last year may not be the best one for them in 2016. Consumers might be able to save money when choosing a new health plan that offers similar health care benefits and coverage. 

Assisters can help consumers by encouraging them to research plan options to compare price, network, etc. As consumers do this, they should bear in mind what health care services they used in 2015 and how much they spent on those services. 

Questions for consumers already enrolled in marketplace plans

  1. Which providers are in the plan’s network? If the consumer currently has a primary care provider, or needs to see a particular specialist, is that provider still in-network?
  2. Does the cost-sharing still fit the consumer’s budget? Specifically, are the co-payments, coinsurance, and deductibles still affordable?
  3. Have the premiums changed? 
  4. Are consumers able to get a plan that’s better for them, and get more financial help paying for it?
  5. Has the deductible changed?
    • Will the plan start paying claims for each family member once the consumer reaches the individual deductible?
    • Or does the entire family need to meet a family deductible?

We’ve created a checklist of questions for enrollment assisters to use to make sure to ask the right questions of the consumers they are helping to enroll. (See our related infographic “7 Questions to Ask When Buying or Renewing Health Insurance in the Marketplace.")

Questions to ask uninsured consumers to help them choose the right health plan 

Concerns about the affordability of health insurance loom large for the consumers who remain uninsured. Naturally, questions about cost will be important to helping these consumers sign up. However, it’s important to help them think through which aspect of cost is most important: out-of-pocket costs, monthly premiums, or medication coverage, to name a few. The questions below should help you focus your conversations with consumers. 

  1. What matters most to the consumer?
    Is it affordability? Being able to see a certain provider? Having access to a nearby pharmacy, hospital, or urgent care center? Or prescription coverage?
  2. How important is monthly cost?
    Navigators should assess the premiums and how much financial assistance a consumer would receive for the plan. The plan that offers the best price may have changed from last year. Also, don’t stop at the premiums; consider the other costs consumers will face when getting care. 
  3. What costs may consumers face in deductibles, copayments, and co-insurance when getting care? 
    The metal levels–bronze, silver, gold, and platinum—refer to the percentage of costs the plan will cover for the average consumer, and give a rough idea of how much of the cost consumers should expect to bear for their annual health care costs. But there can still be significant differences between plan costs within each metal level. It’s important for consumers to consider how much they are willing to spend out of pocket every year, in addition to their monthly premium. Consumers want to be sure, for example, that they can pay for doctor visits until they’ve met the plan’s deductible. 
    Tip: For more details on the services covered, look at the summary of benefits and coverage for examples. Ask consumers how much they spent on health care in 2015.


  4. Does the plan cover the consumer’s medications and, if so, what are the copays? 
  5. How many times per year will the plan pay for specific services a consumer needs? 
    Some plans limit the number of physical therapy or speech therapy visits that they cover per year, for example. Likewise, if there are certain services that a consumer uses, check to see whether there are any limits to the plan’s coverage of those services.
  6. What level of out-of-pocket expenses must a consumer pay before the plan begins paying for health care services? 
  7. Are consumers getting the care they need? Look at the plan’s provider network to make sure
    • If there are particular providers the consumer would like to visit, are they in-network?
    • What type of plan is it? Is it an HMO, PPO, EPO, or POS plan? 
    • Will the consumer need to get a referral from a primary care provider to see specialists?
    • Will the plan pay anything if out-of-network services are used?

Our fact sheet offers more details about questions to ask consumers while they are selecting a health plan. When working with consumers who have disabilities, this guide from the National Disability Navigator Resource Collaborative can help. AHIP has also written a guide that helps consumers learn more about health plan networks

How to find benefits and coverage information for individual health plans

Consumers and enrollment assisters in federally facilitated marketplaces can find information about the plans sold in the marketplace by simply clicking on the name of the plan. All health plans must provide an easy-to-read summary of their benefits and coverage that looks like this. It shows what a consumer would pay and what the plan would cover, for various services. Consumers and enrollment assisters can find links to these plan summaries on the marketplace for each state.

Remember, in order for consumers to get the plan that meets their needs, they need to stop, shop, and enroll in the plan that’s right for them this open enrollment.