Open Season is almost over.  I know that many of you just can’t decide what’s the best plan- which one will work for you.  It’s hard to predict what drugs you’ll need, if you’ll contract a bug, or just be fine.

But, regardless of whether there are financial penalties, you really do need insurance.  Not only to preclude you from having to file bankruptcy if your health goes south or you need expensive health treatments, but to belong to a “buying club”, which is what insurance really is.  You get better (cheaper) fees and costs when you have insurance coverage.

The program  (PPACA, aka Obamacare) offers four different levels of insurance, and to make it simple (or at least they think so), the precious metal analogy is used.  We have the Bronze, Silver, Gold, and Platinum choices.  As the metal gets more precious  (which means the insurance plan covers more of our out-of-pocket expenses), the premiums increase.  Basically, the Bronze Plan will cover 60% of the costs of one’s health needs, Silver ups that level to 70%, Gold covers 80%, and Platinum reaches the 90% cost level.

No matter the tier, there are minimum essential healthcare benefits, as seen above.  (Please note that I am not discussing those useless plans that are being bandied about by the current administration that are temporary, offer little real coverage- but, are cheap as hell.) And, while the bronze and silver plans cover our healthcare needs, we still have higher out-of-pocket costs and lower premiums than those that exist in the higher tiered plans.

The choice among the plans- not only the range from Bronze to Platinum- but the choices among the four different levels- is highly individual.  First of all, there are subsidies for those whose income is less than 400% of the poverty line.   (Don’t scoff- a family of 4 can be subsidized if the family income does not exceed $ 100,400!)  Those subsidies are available ONLY for the silver echelon plans.  So, if your income level affords the subsidy, you need to look at the subsidized cost and then evaluate what that means for your total out-of-pocket PLUS the premium costs.  Sometimes, the subsidy for the lower plan plus the cost for your drugs means a higher cost, unsubsidized plan would be the better option.

That’s why a higher tiered plan, with its lower out-of-pocket costs, can be cheaper on an annual basis than that lower tiered plan.  And, then, there’s this fact- the silver plans (considered the “benchmark” plan) is actually more expensive than the higher tiered, gold plan in about 1200 counties across the US.

Why?  Because most of the folks who opt for the silver plan are going to obtain a subsidy.  And, that subsidy means the silver plan costs are substantially cheaper than the list price.  However, if you are not entitled to the subsidy- the gold plan could be the better choice.  (You do remember that TheDonald ended the reimbursement to the insurers for those mandated discounts.  So, the insurers simply upped the plan’s costs to cover some of their lost revenue.)

But, there are other considerations.   What happens if you visit a shrink each week?  Or, you need physical therapy.  I had a few clients who opted for the most expensive choices so these costs would be covered.  But, after we discussed their options, they realized my idea of going for a cheaper plan- and paying for the therapy out-of-pocket, meant one’s monthly health care costs were actually lower- even though the plan didn’t cover the costs about which they worried.

That’s why you have to examine each plan.   Is your current doctor included in their coverage?  If you take drugs (so many of us take cholesterol-reducing and blood-pressure-maintenance drugs), are those pharmaceuticals available at a very low-cost or free in the plan you are choosing?  You must choose your plan based upon the real cost- not the sticker price of monthly premiums.

That becomes more important when you realize that some of the plans have cost-sharing (a co-payment) before one reaches the deductible, for certain medical services. A bronze plan may not cover routine doctor visits, while the silver plan will- without a co-payment.  Those cost-sharing bills add up- and it often means you can end up spending the entire out-of-pocket maximum!

(In one special case- that may apply to you, we set up a Medical Health and Dental Reimbursement plan for the client’s employees.  That meant the company could cover the out-of-pocket expenses.  And, that was cheaper than offering a more expensive plan on an annual basis.)

Here’s another special case- for millennials. For those under the age of 30, opting for catastrophic coverage can save you a bundle.  Sure, this kind of plan won’t cover the essential healthcare costs (but most millennials think they are Superman and will never need to visit the doctor), but it will cover your rear end should you incur a major accident or develop a major illness.  (In other words, having this coverage means you won’t have to file what has become known as ‘medical bankruptcy’- your medical bills [especially since you didn’t join the buying club that health insurance really provides] won’t exceed your ability to pay.)

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As I alluded above, TheDonald has allowed Healthcare.gov (and the individual states that run their own program) to offer short-term medical plans and MEWA’s  (insurance pools that provide lesser benefits).  But don’t fall for the hype that these plans will save you (I say you, because I am an old fart, covered by Medicare, not PPACA) money.

These plans simply suck.  Yes, folks will tell us that the larger firms use these routinely to insure their employees.  Surprise- that’s absolutely true.  Because those firms only rely on these plans to re-insure their own healthcare programs (that means there is also a stop-gap, a safety net, that these firms also have- and you, as an individual, do not have!).

These can cover some of the potential losses- for firms, not individuals.  Those bigger firms that self-insure have computed that they can save money by covering the initial health care costs and defer to the insurers to pick up the tab for larger bills.  That is what keeps their premiums low.  (I provided an example that WalMart is actually sending employees diagnosed with cancer to the Mayo Clinic- so a cost-effective (and health-effective) plan can be developed.  Walmart recognizes this additional step will save them a ton of money in the long run.)

We “little people”  lack those reserves and resources!  So, the big question should we opt for these ‘bait-and-switch’ programs is:  How are we going to cover our initial costs?   Where will we get that money?  We already know that when smaller firms used these programs before, the insurance plans often leaving the firms and their employees with some bills.  Or, worse yet, those sort of plans have been known to file for bankruptcy.  Leaving us with the large bill upon which they defaulted.  Oops….

Don’t forget that you (if you are a female) will probably have to check WAY MORE carefully into your choice of plans- since the government killed the requirement that the plans include birth control provisions, too.

Back when I was participating in Obamacare [I told you- I am an old fart, so my health care plan is Medicare and Medicare Advantage], my plan increased by 25% had I decided to stay with the same options for renewal.  But, I examined all the choices (both  in the same tier and a few higher ones) and switched to an alternative plan [having the same doctor choices and coverage] for a few pennies different than I had already been paying.  And, year 3, with a similar price increase on the horizon, I switched back to plan 1- for, actually, a lower price than I paid for health care in year 2.)

Please, please, please do this!   Because you probably don’t realize another shenanigan that has been perpetrated…  If we do nothing, we may find that we’ve been re-enrolled in the same plan.  With those higher rates.  (You probably don’t recall agreeing to automatically re-enroll.  You did.)  And, that re-enrollment this year happens AFTER the open enrollment period has expired.  So, we won’t be notified of our error (it’s OUR error if we do nothing), until it’s too late.  When we can’t get that better or same plan at a lower rate.

Another vagary?  Some insurers are offering ZERO cost plans.  And, that’s true for almost all of the 2922 counties across the US.  (To the best of my knowledge, this seems to be happening in about 2700 counties.)  The availability of a “free plan” depends upon family income, household size, age, where we live, and whether we have access to other health care plans.

So, hurry up and check out those plans.  Because the clock is ticking- and you need health insurance!