CT health insurance: How to pick a plan

A contributing columnist once wrote in The New York Times : “A confession: I am a health economist, and I cannot rationally select a health plan.” So if picking a plan feels like an impossible task, you’re in good company.

Maybe you just moved to Connecticut, had a change in employment or income, or you’re turning 26 and set to get kicked off your parents’ plan. All of these life events, and several others, mean you might be looking to enroll in a new plan.

Knowing what to look for when selecting coverage can be overwhelming. Here’s a breakdown.

Terms to know

When shopping for a health plan, you’re likely to see lots of terms that aren’t very clearly explained. Here are a few helpful definitions.

These are the terms that refer to your regular expenses.

• Premium: the amount you pay each month to your insurance provider to have your plan
• Copays: flat fees for specific services. For example, a plan might have a $10 copay for primary care visits and a $20 copay for specialist visits. In that case, you’ll have to pay $10 when you see your primary care provider and $20 when you see a specialist

Then there are the terms that relate to the design of a plan.

• Deductible: the amount you have to pay for your own health care in a year before insurance pays anything
• Co-insurance: once you hit your deductible, you and the insurance company will begin splitting the cost of care. Co-insurance tells you how much you’re responsible for versus the insurer.
• Out-of-pocket maximum: the maximum amount you’ll pay for in-network care in a year. Once you hit this, your plan will, in general, cover your care.

Let’s say a plan has a $5,000 deductible, 50/50 coinsurance, and a $10,000 out-of-pocket maximum. If you get a surgery that costs $8,000, you’d have to pay the first $5,000 in full. For the remaining $3,000, you and the insurance company would split it 50/50, so you’d be responsible for an additional $1,500, or a total of $6,500 for the $8,000 procedure. If you spend more than the out-of-pocket maximum of $10,000 on care in a year, you no longer have to split the cost 50/50, and your insurance provider will, in general, cover 100% of the costs for in-network care.

“In-network” providers have contracts with your health plan to provide care. You can confirm whether your current providers, or any others, are in-network for a certain plan by visiting the insurance provider’s online portal.

The majority of plans also enable you to get certain services for free, without having to pay copays or coinsurance, even if you haven’t met your deductible, as long as you go to an in-network provider. These are known as “preventive services” and include annual wellness visits and breast cancer screenings for women over 40. You can find a full list of preventive services for adults, women and children here .

“People sign up for health plans and then don’t use them at all throughout the year because they’re terrified, especially if they have a higher deductible health plan,” said Caroline Ruwet, the marketing director at Access Health CT. “Your preventive care comes at no cost other than that monthly payment to have your plan.”

Coming across other terms that you want to better understand? Here’s a full health insurance glossary.

Selecting an employer-sponsored plan

If your employer gives a document with a description of all the health plan options it offers, here’s how to think about your decision.

There are two prominent plan types: HMO, which stands for health maintenance organization, and PPO, or preferred provider organization. HMO plans are typically cheaper but offer less flexibility as a patient. You’ll probably have to select a primary care physician and then go through them for referrals before you can see specialists. PPOs are typically more expensive, but offer you more flexibility, like seeing out-of-network providers (at an extra cost) or seeing specialists without a referral.

Plans with lower premiums, or monthly fees, typically have a higher deductible, or amount you have to pay for care before insurance kicks in. Conversely, plans with higher premiums tend to have lower deductibles. One way to think about which plan to select is to consider a decision between cost and coverage. Those who are relatively healthy and don’t typically see the doctor very often, may select a high-deductible plan to save a few bucks every month. But, those who have a reason to see a doctor pretty often, like a chronic illness or plans to start a family, may opt for a plan with a higher monthly premium and a lower deductible.

Don’t qualify for employer-sponsored coverage?

If you don’t have access to employer-sponsored coverage, you can visit AccessHealthCT.com , the state’s health care marketplace. Access Health CT is a one-stop shop: it’s where you can both find out what type of coverage you qualify for and enroll in a plan. You’ll have to fill out personal information, including your household size, residence and income, and the site will then tell you whether you qualify for Medicaid , a no-cost Covered CT plan or subsidies to help you cover the cost of a qualified health plan. Even those who don’t qualify for any type of subsidized care, can still purchase a plan through the exchange.

“It’s a pretty simple process,” said Sean King, the acting director for the office of the health advocate. For those who don’t have coverage through their employer, the plans on Access Health CT “are typically your best options for comprehensive coverage,” he added.

‘Get help’

There are a host of resources available to Connecticut residents to help with the process of selecting coverage.

Certified insurance brokers can recommend the best plan for you and your family based on your available options at no cost. For those navigating Access Health CT, certified application counselors are available at places like hospitals and emergency rooms. They can’t legally recommend a plan, but they can help you understand your options. The Access Health CT call center can also offer assistance in 100 languages.

“You don’t have to do it alone. It’s so complicated. Get help,” said Ruwet.

For a full list of available resources to help you pick a plan, including certified insurance brokers and application counselors in your area, visit Accesshealthct.com/get-help/ .