a field guide to health insurance

We're moving, so the Gardener is leaving her job, which means she needs health insurance. Grad school doesn't cover partner benefits (for anyone, not just for queer partners), so it's the private market. Have I ever mentioned how godawful it is to buy private health insurance? Even though we're both young and healthy - and thus privately insurable - it's a damn mess. There's no standard format for the policy description, so it's practically impossible to directly compare plans: ehealthinsurance is the closest I've found to something that will do that, but it's sometimes hard to interpret. For example: the Kaiser plan lists out of network services as "not covered." What that actually means, according to the Kaiser representative I called, is that only emergency and urgent care are covered out of network. Which is good, because insurance that doesn't cover you in an accident when you're out of town doesn't hedge your risk very effectively.

So this is a half-genius idea. Senator Jay Rockefeller (D-WV) wants to create some kind of guide to health insurance via a non-profit trust. The plan is to give letter grades in categories like adequacy of coverage, affordability, transparency, blah blah blah. Great idea. I'd love to have some real reputational data on the insurers I've been looking into. But even more than that, what I need is a standard format for the underlying coverage data. I need to be able to know exactly what I'm comparing to what. Kind of like a nutrition label, but with money.

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I've spent a lot of time on the phone researching this, so let me tell you how to pick your health insurance (on the off-chance that it's useful to one of this blog's 2 readers):

1. Look at the premium, then stop looking at the premium. This is the least useful piece of information available, except insofar as it rules out the plans that are far too expensive for you. More expensive plans are not always better.

2. The deductible. That's how much you have to pay, right off, if you get hospitalized/seriously ill/whatever. It should be an amount that will not destroy you financially, because in fact that's a major reason for having health insurance. But plan that if you get hit by a truck, you will be out this money right away. In fact, if you're the sort of person who keeps money around for emergencies, it would totally make sense to keep that money in your emergency cash account. If you have solid savings and usually use minimal medical care, it might make sense to have a high deductible plan; but you're making a bet that you won't need to pay the deductible.

3. But that's not all! What services have the deductible waived? Many plans waive the deductible for primary care or specialist visits, so if you have a suspicious mole and need to go to the dermatologist, you don't have to pay the full office fee yourself.

Some plans waive the deductible for only a certain number of visits: Anthem Blue Cross has a plan that's directly aimed at young healthy people and covers only 4 doctor visits/year. Basically, you can get a pap smear and go to the doctor to get your strep throat checked out, but anything chronic or weird or hard to diagnose is going to cost you the deductible. So if you take a plan like this, you're essentially betting that you're not going to develop a chronic or complicated health problem: it's good for catastrophic situations and preventive care, but not for things that are in between.

4. Still not all! What you really need to keep your eye on is the Out of Pocket Maximum. Even after you've paid the deductible, you're still responsible for co-insurance. Frankly, I don't really worry about the co-insurance percentage: you end up having to pay between 20% and 50% of your costs other than office visits once you've hit the deductible, but once you're in the hospital or getting surgery everything is so damn expensive that I figure I'll end up hitting the Out of Pocket Max if something like that happens. So. That's what I worry about. And here, you need to be careful. Sometimes the OOPM is listed as an additional amount after the deductible; sometimes it includes the deductible. I looked at an Aetna plan that listed the OOPM as $8000 in network or $12,500 out of network when you figure the deductible in. I figured that would mean the total OOPM - the amount I'd be liable for in a real health problem - would be $12,500, but I called to check and boy was I wrong. The in network and out of network costs rack up separately, so the real OOPM was $20,500.

The OOPM should also be an amount that will not destroy you financially, that you could come up with via credit cards or loans from family or a payment plan from the hospital, and that would not force you to declare bankruptcy. We looked for plans with an OOPM between $3000 and $5000. It would suck to come up with that, but I bet we could. $20,500? Not so much.

5. Lifetime maximum benefit does matter. If something really bad happens (cancer, etc), you can run through a low lifetime max in a couple of years. I would prefer to have a plan with no lifetime maximum benefit, and am actually a little worried about the fact that my grad school health insurance has a $400,000 lifetime max. If I had to choose a plan with a lifetime max, I'd rather have it be over $5 million.

6. How much do you hate referrals? If you really hate them - if they keep you from going to specialists because you hate them so much - get a PPO instead of an HMO. Otherwise, I wouldn't worry that much about the distinction (unless you have a particular doctor/specialist you really need to see).

7. Here's my theory on mental health coverage: if you need it, because you have a mental health condition that requires ongoing management, worry about mental health coverage, but worry about prescription coverage more. I basically think bad therapy is useless, and that it's hard enough to find a good therapist that even if your insurance covers therapy, there's a good chance you'll end up paying out of pocket anyway. If you're the kind of person who sometimes likes to see a therapist to talk about your family, get advice about transitions, etc, don't bother worrying about mental health coverage. (All of this, of course, is for people who have a fairly clear handle on their own mental states: sometimes these change, and you suddenly need more treatment than you used to. And if you have kids, it probably really is worth worrying about mental health coverage, because you never know how they're going to turn out.)

8. Speaking of prescriptions, I found several plans that cover only generic drugs. This doesn't really make sense to me, because it leaves you exposed to substantial risk of very expensive medical bills.

9. Try calling the insurer to ask questions. If the person you reach isn't helpful, they're not going to get any more helpful once you've bought the insurance.

10. Insurance is more expensive for women. I don't really have anything to say about this, other than that it sucks and is dumb.