Answers about health insurance from your old 201 UCB instructor

I get a lot of questions about health insurance around this time of year. I was an actor and improv instructor for many years before I went back to grad school and got into the health policy game. These days, I work for a health insurance company on new Medicaid policy implementation (a job I love), but almost everyone else I love is still in the arts and out of the employer-based health insurance pool. I thought I’d put together my recommendations for this year based on the questions I usually get. Obviously, these reflect my personal opinion only.

Q. Do I need to get health insurance? I’m pretty healthy.

A. Yes, you do. Your mother thinks so and so do I. First of all, it’s important in case anything major happens (god forbid) to have some buffer against how expensive medical care can be. Secondly, there’s a penalty for not having health insurance (at least for now). Thirdly, there’s a good chance that some big things are going to change in the insurance market under a Trump presidency. One of the ideas favored by his new pick for HHS secretary, Tom Price, is to bring back denial of coverage for those who have a preexisting condition and an interruption in their coverage in the past 18 months. Here’s more info on Price’s proposal. There are other reasons, but just take it from me that you should do it. Open enrollment ends January 31, 2017. After that, you’re shit out of luck (unless you qualify for a “special enrollment period).

Q. Where should I get my insurance?

A. Check your state’s exchange for your eligibility. In most cases, if you don’t have insurance through your employer, the most reasonably priced option is to go through your state health exchange. In California, this is called Covered California. The great thing about these exchanges is that they have a “no wrong door” policy. Meaning, if you’re eligible for coverage through the exchange, they’ll sign you up for that and help you determine if you’ll get some help paying for it (often called a “subsidy”). If you didn’t quite make enough dough last year, they’ll direct you toward Medicaid. Eligibility is complicated and occasionally, a family will get split between coverage on the exchange and Medicaid. If this happens to you, don’t worry. Medicaid can be good insurance.

Q. But isn’t Medicaid bad insurance?

A. No! It can be great. Medicaid gets a bad rap. In many states, Medicaid has been expanded in the past few years to cover people with moderate to low incomes, many childless adults, and undocumented folks. In California, Medicaid largely lives within managed care. This means that you may end up with a familiar health plan like Molina or Anthem Blue Cross. The networks and benefits may be a little different than commercial plans, but you probably won’t notice a huge difference. And for most people, it’s free! Can’t beat that.

Q. How do I chose a plan on the exchange?

A. It depends on how much health care you use. Are you someone who goes to the doctor a lot? Do you have regular medications that you take? Are you currently receiving care somewhere for a serious medical condition? How risk averse are you?

If you are generally healthy and you don’t mind a little extra risk, you may want to go for a higher deductible plan with lower monthly premiums. If you have some special considerations (a specific medication, a specific doctor you want to keep, etc.), you probably want a plan with more coverage, a lower deductible, and a reasonable out of pocket limit. You’ll pay more per month, but the risk will be mitigated.

Q. What’s a deductible?

A. It’s the amount you have to pay before your insurance really kicks into gear. These are getting higher and higher so make sure you look at this.

Q. What is coinsurance? How is it different than a copay?

A. It’s the % you will pay for certain services. For instance, let’s say that you have a 20% coinsurance for any inpatient care. If your hospital bill costs $1,000, you’re on the hook for $200 and your insurance company pays the rest. If your bill is $20,000, you’re on the hook for $4,000. This is mitigated by an out-of-pocket maximum. A copay is a fixed amount you pay for a specific service. For example, every time you go to see your primary care physician, you may have to pay $25. This amount doesn’t change if the other costs associated with the visit go up.

Q. What’s an out-of-pocket maximum?

A. It’s the most you’ll have to pay for in-network services. This is a pretty new and wonderful element of many insurance plans these days. It’s puts a cap on your risk exposure, but usually only for in-network services. If you go out-of-network, all bets are off.

A parting request.

Finally, if you’ve benefited at all from Obamacare in the past few years, I encourage you to share your story with Families USA. They’re a great organization that’s going to fight hard to keep many of the gains we’ve made in health care since 2010.

I hope this helps! Let me know if you have any questions. And don’t forget to really blow out your second beat games.