Love it or hate it, the Affordable Care Act is here and in full swing. Its second open enrollment period is about to start, and now is the time to decide if you need to make changes to your health plan – whether you have insurance through your employer, through the insurance exchanges that opened in 2013 or none at all.
Open enrollment for plans provided through HealthCare.gov and the state exchanges officially starts Saturday, Nov. 15. The federal marketplace will stay open until Feb. 15, 2015 for people who want to gain, drop or switch insurance policies.
If you have a plan provided by your employer, you’ll likely have a few weeks of open enrollment this month or next. Regardless of the source of your health insurance, your window to make changes is coming up quickly. So: Should you make a change?
Sometimes, It’s Better to Stay Put
1. You plan to have a baby.
Under the Affordable Care Act, maternity, delivery and newborn care are covered by insurance. However, if you plan on having a baby soon it’s worth taking some time to evaluate the quality of your current plan. Expectant mothers and newborns need more doctor visits, exams and blood tests than most people, and the out-of-pocket costs for these services can really add up.
Then there’s the cost of delivery. Uncomplicated vaginal births cost an average of about $30,000, while uncomplicated cesarean sections cost an average of $50,000. You will pay a fraction of that, but your portion can vary by thousands depending on your insurance plan. For a family, the maximum allowed deductible is $13,200 for 2015 – meaning you could be responsible for paying this amount before your insurance covers anything.
If you’re planning on having a baby soon, your best bet is likely a plan with a low deductible and low cost-sharing (copays, coinsurance). This type of plan generally comes with higher monthly premiums, but it can pay off when the baby comes. The last thing you want to worry about when you have a new bundle of joy is medical debt.
2. You have a new chronic diagnosis.
If you’ve recently been diagnosed with a chronic condition, there are some things to think about when it comes to health insurance. If your health insurance doesn’t go far enough to cover the drugs and services you’ll need going forward, it may be time to upgrade. The good news is that, under the ACA, you can’t be penalized for a pre-existing condition when you get new health insurance.
But be careful when switching. Your specialist is going to be key to your disease management, and if you have one you like, you’ll want to keep that doctor – and that could be pricey if he or she is out-of-network on your new plan. Check before switching to see which insurance plans your preferred specialist takes, and narrow down from there.
However, if your diagnosis is new, you may not have a preferred specialist yet. In that case, your new insurance coverage should have a large network of specialists for you to choose from. Whether it’s a neurologist or a gastroenterologist you need, it’s key to have lots of options. Even if you do have a preferred specialist, a large network is good as a backup in case he or she moves or is unavailable when you need care.
Comprehensive drug coverage is also a must if you need regular medication. If your current insurance plan only covers certain medications, you may want to look for a plan with a broader drug formulary, or list of automatically covered drugs. Drugs not on the formulary may be harder to get covered by insurance.
Marketplace plans cover about 60 to 90 percent of your total costs during a given year, depending on the metal tier you select. If you anticipate needing more medical care than you have in the past, a plan that covers closer to the 90 percent end of the spectrum is probably worth your money, despite the higher premiums.
3. You’re becoming an empty nester.
If you have a child entering college or turning 27 in 2015, you may have a good reason to downgrade your insurance. Don’t make the mistake of thinking your insurance company will make the changes for you. If your adult child is turning 27 this year (and thus can no longer be included in your family plan), you’ll want to speak with your insurance representative about that during open enrollment. This applies whether or not you have employer-offered insurance.
If your child went off to college this semester, you can also check into student insurance plans. In many cases, students can receive insurance from the university that covers them at campus clinics or teaching hospitals, and this option may be cheaper than keeping them on your plan.
In addition to being less expensive than keeping your son or daughter on your plan, there may be other advantages to student insurance. If your current insurance network is limited, there may be few covered care options in the college’s area. In an emergency, medical care near campus could be lifesaving.
This article originally appeared in U.S. News.
Doctor and patient image via Shutterstock.