Every year you’re offered the opportunity to choose your health plan for the year—whether through your employer, the open market, or Medicare. Who helps you make this important decision that impacts your health and your wallet? Our experts provide a simple system you can follow to make a decision that’s tailored to your health needs.
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Joyce Griggs: Hello everyone and welcome to our regular conversation with our experts on all things insurance and what we can do to make all the right choices when it comes to this part of our healthcare. And I'm joined today, as I always am on this important topic, with our experts Jordan Shields and Dr. Alan Feren. And today we are talking about how to choose your medical insurance plan and how you can make informed decisions about the options that are put in front of you.
We have our employers and our employers offer options to us. You might be on the individual market, whatever your options are, there's a lot of them. And it's really hard to kind of go through and decide what is it that you're going to choose. There's different designs, there's different carriers, there's all sorts of things available to us. We're gonna start off our conversation today with Jordan kind of walking us through. Can you just tell us, where do we start? It's feels like a mess.
Jordan Shields: I have no idea. Wouldn't know where to begin. Oh, wait. Oh, it is my, it is my turn. Okay. Yes, I do know where to begin. You know, the important thing is, with anything, when you have a lot of options, you have to be able to set context and you want to just drill it down to what are the main things that I need to know.
So when I talk to clients, whether on an individual basis or on a group basis, and you have a lot of options in the market and many employers will say, we've got five different carriers, or all these different plans, how do you break it down? So I use the rule of three.
There are three systems you have to consider. There are three factors you have to consider in making your decision. There are three variables that need to come into play depending on who you are and what medical needs you have. And then finally, and the big finish for me is always, the three scenarios. Now that you know what information you have, how do you line 'em up so you can make a decision?
The important thing to remember though is that any decision you make is only for a year. If you be individual or the market exchange market, they have an open enrollment period. So from this period to this period, that's when you're making your decision. When you're working with an employer plan, they say it's our open enrollment period. You're only making that decision for a year. So this year you're gonna get pregnant. Next year you've got major surgery. The year after that you have nothing. Each year you can make a separate decision based on your situation.
That's the general context. We break it into the rule of three, and I can, you know, break that down into each of those rules of three for you.
Joyce Griggs: Okay.
Alan Feren, M.D.: Jordan, can you, can you tell us what is this system? Cause I think a lot of people don't understand that.
Jordan Shields: When you're dealing with the medical system, it, it's where the medical care is being delivered. Not necessarily from a hospital or from a medical clinic. But how it's filtering through payment. So you have three basic systems.
You have the closed or staff model HMO, and HMO stands for Health Maintenance Organization.
You have an open HMO, which uses an IPA, which is an Independent Positions Association.
And then you have a PPO, which is a Preferred Provider Organization.
Way back when I started in the business, the only plan out there was called an Indemnity Plan, and that's kind of what a PPO is. Indemnity basically says, you file a claim, here's what we're gonna pay you, we're indemnifying you against a loss. And that's the basic underlying principle of insurance. When HMOs came in in 1973, they actually existed before that, but they were formalized by the 1973 HMO Act, there were two kinds: a closed model. You don't see those too often. We certainly see where we are in Northern California. You have Kaiser. Kaiser is the largest staff model HMO in the country. But there are also others. There's Harvard Pilgrim in Massachusetts. There's Puget Sound, Puget Health in Oregon. Tufts used to be a closed model. There are a couple little pockets of those model HMOs, and what they mean is that they have an entire system. We have the hospital, we've got the clinic, we've got the pharmacy, we've got all these different testing devices, and so on. Everything is there on one big campus or on one big campus with several satellites. And once you go into that system, you just use the system, and you walk in. Green line, go to X-ray. Yellow line, go to to lab. Red line, go to the doctor's office. Pretty simple, pretty straightforward, but it's their system. They run it their way. And if you want to go outside the system, you're gonna have to ask their permission. It can be a bit of a problem. So good news is simple, easy to use, you know where you're going, they're gonna tell you where you're going. The bad news is that if you don't like what they're telling you, you're outta luck.
Joyce Griggs: Mm-hmm.
Jordan Shields: It's all about them in the system and working with you in collaboration. Not so much about you directing it.
On the other side of the spectrum is the PPO, where you can go see anybody you want, anytime you want. The trick though, is that because it's a Preferred Provider Organization, the benefits you're looking at when you're reviewing everything under the insurance is all geared towards when I use a preferred provider, this is what my payments are gonna be. And we always steer you in that direction when we're looking at it, too. Because if you use an unlisted provider, there are penalties.
Joyce Griggs: Mm-hmm.
Jordan Shields: So that's open-ended. Go anywhere you want, anytime you want. See anybody you want. Here you see who we tell you you're gonna see, and in the middle is the HMO that's called an Independent Physician's Association. You pick a doctor that's in a group called a PMG or Primary Medical Group. You pick that doctor in that group and they'll put that name on your card and that doctor will steer your traffic through the system. So it's gonna be an OB-GYN. It's gonna be a family practice doctor, general practitioner, whatever. So they are the link to the system, but the system isn't necessarily enclosed in one giant, monolithic, you know, hospital and clinic thing. It could be different hospitals, different doctors in your area. Those are three systems, and that was supposed to be three systems in a nutshell.
It's a pretty large nut, pretty large shell.
Alan Feren, M.D.: So it's really about choice. I think it's really important to understand that, and on the physician's side, because I am the recipient of whether this is an HMO, a PPO, or an IPA model, it's a discount.
I remember when PPOs first started and the person came to detail me, and it was a kind of a rude woman, unfortunately, but she basically said, your waiting room is gonna be empty unless you subscribe to this PPO.
So PPO is a discount of physicians as physician payment. So that what you see on the bill is not necessarily what the physician actually is getting, and that's particularly true when you look at Medicare.
Jordan Shields: And you'll see those discounts when you get your benefit statement. You filed a claim and it'll show, this is what the charge was, this is what we "allowed," and it'll even tell you at the bottom, it'll say, you don't owe that difference between what was allowed and what was charged.
There's another, a deeper discount program, and I don't really talk about it in depth because it doesn't come up very often, but you may find something called an EPO, which is Exclusive Provider Organization, and it's the same as a PPO where you have choice to use anybody you want, but it's a smaller list of providers. And if you go outside the system, usually there's no coverage at all. So the coverage is a lot like the HMO. But it does allow you to choose anybody you want. And when I say anybody you want, I mean, like if I'm in San Francisco and I wanna see Dr. Jones at Stanford and he's recommending Dr. Smith in Corpus Christi, Texas, I can do that. With an HMO I, I really can't. Or he might not even recommend I see a doctor, but I wanna get a second opinion from Dr. Jones at Corpus Christi and I can go do that in a, in a PPO or in an EPO if they're on the list. In an HMO environment, I can't do that. So a lot of freedom. And you're gonna pay more for that freedom, which we can get to in a bit.
Joyce Griggs: Mm-hmm. So lemme just ask one more question. So there's the the closed HMO, which is like a system like Kaiser. There's the open HMO which means I have to pick a primary care provider. That primary care provider is like what we used to call the gatekeeper in terms of how, how I can see different specialists and things, things like that. And then it's just those doctors and other healthcare professionals that are part of that HMO that I can see?
Jordan Shields: Yep. Through the gatekeeper .
Alan Feren, M.D.: A good way to characterize this, Joyce, is you talk about network. So the network really in an HMO is very narrow. With a PPO, it's a wider network. So the choice that Jordan is talking about can go anywhere and see any of these doctors. You still should have your gatekeeper or your primary care physician because you need someone who's the captain of the ship to direct the care to advise you if you've got such and such a problem, go see so-and-so who's a specialist in that area.
Joyce Griggs: Mm-hmm.
Alan Feren, M.D.: And that would be true even in an IPA model, you still should have a primary care physician.
Joyce Griggs: Mm-hmm. You still want your primary care physician, but if I decide in the Preferred Provider Organization, if I'm in that type of care that I wanna go see a cardiologist, I don't need to get the permission or the referral from my primary care.
Alan Feren, M.D.: Correct.
Joyce Griggs: I can make that decision on my own, if I want to. I'm not saying that that's the best way of going forward, but you do have that freedom to do that type of thing.
Alan Feren, M.D.: Correct.
Jordan Shields: But then the cardiologist will say, who's your primary care physician?
Joyce Griggs: Of course.
Jordan Shields: They're gonna want your records and all that. So as Alan said, it's good to steer it through the primary care physician anyway. But if you need to see somebody and you know this cardiologist and wanna go see him, go for it.
Joyce Griggs: Right.
Alan Feren, M.D.: Just to be clear, some HMOs do have the ability to go directly to a specialist.
Joyce Griggs: Okay.
Alan Feren, M.D.: So that it's not, yeah. It's not always that you need to have a primary care referral.
Joyce Griggs: Okay. Okay. And are PPOs available to us if we're buying our insurance through the marketplace? Through so-called Obamacare?
Jordan Shields: Yes. However, what you'll find certainly in the individual market, the PPO provider list, let's just say, is this big on a group plan.
Joyce Griggs: Okay.
Jordan Shields: But on many individual plans now, they have now started to use narrow networks. And the reason is when the Affordable Care Act came out, and they said that every carrier has to accept every applicant at least once a year during the open enrollment, the carriers went, man, we're gonna get bombarded with a bunch of people that have, you know, untapped, unused medical care, and all of a sudden, boom, they want to come in and get the surgery and they're gonna drop off again.
And they're not wrong about that, and so they watched their prices go up. So as the internal cost of those plans went up, and they've gone up substantially and we knew that they would, they also said, well, what can we do to kind of contain this demand? And so they started squeezing out narrower network, which is typically about 50 or 60% of the size of an ordinary group PPO network. So be advised that if you're looking at plans from an individual standpoint, you have to make sure you're choosing the right network within that market exchange. It's not just using anybody.
And even when you talk to your doctor, the doctor may know which network they're on and they may not. So you really need to be very careful that you're looking at this and talking to their office manager and double checking with the website.
Joyce Griggs: Okay. All right. This is great. So that's the best way to make sure that my doctor is in my system is to look for that to make sure that that's happening.
Jordan Shields: You wanna crosscheck it, look at the website and talk to the doctor's office 'cause the website may be slightly outta date.
Joyce Griggs: Yeah.
Jordan Shields: Or the doctor's office may be slightly outta date. So make sure that they're in harmony and then you're okay.
Joyce Griggs: That's awesome. Okay, so three systems. What's our next three?
Jordan Shields: So then there're the three factors that you need to look at and fortunately these are pretty simple. And just a couple of notes that I give people when they're trying to look at things.
You're gonna have different premiums or costs for all these different plans. Make sure you know what the cost of the plans are, because when we get to the scenarios that you're gonna use for selection, you gotta be able to plug in those numbers. So if it's for me and my spouse and my two kids, whatever the total cost is, I need to know the cost of the plan to figure out which is going to be best for me. Cuz it's not always about choice, it's not always about coverage. Sometimes you have to weigh cost versus coverage and so on. So premium is one thing, location is another and it relates back to what we were talking about. Using Kaiser as an example for Northern California, Kaiser only goes so far. They, they go up to, you know, a metropolitan area, but beyond that metropolitan area, Kaiser does not exist. So if you're living more than 30 miles outside the most distant outpost of an organization. They're not going to cover you. You couldn't take Kaiser if you're 200 miles away from it, even if your employer says, we have Kaiser. Yeah, but I actually can't use it. So you need to be cognizant of the location and what impact, if any, it's going to have on your selection of a system.
And then the final thing is just a quick note. That whatever plan you choose, if you've got your family on the plan, they're choosing the same plan as you. So you don't say, well, I'll take this and my wife will take that and then a kid. And one of the things that concerns them, we get this call a lot, I said, well, yeah, but I'm in San Francisco, but my son is going to Harvard. Am I going to be covered? And, and I have an HMO and Harvard is way outside the HMO network. Am I gonna be covered? The answer is yes. An HMO will cover you for an out of area life or death emergency. So my son gets hit by a car, you know, on Harvard yard. They're covered. They're gonna be fine. If he has a fever of 101 and he is not feeling very well, I'm gonna say well go to a local clinic. But, you're not gonna be covered on the HMO. They want you to be in their system whenever you can.
So they make an exception for life or death. Emergency. And if my son had some medical issue and they're calling the doctor back here, they can come back here and get their treatment there. So family coverage, everyone in the family's gonna be on the same plan, with the same carrier, the same network. You can choose different doctors within the network, but you're all pretty much tied together. So those are three factors to consider before you get started.
Joyce Griggs: Okay. And then under cost, I mean, you mentioned premiums, but are there other costs that we should be noting when we're comparing these plans?
Jordan Shields: Yeah. The, the total cost of your coverage is going to be your premium. That's a fixed cost. You're gonna be paying this every month or every quarter. And then the variable costs are gonna be what the coverage has to say, and I, and I'll get to that when I talk about the scenarios. But, but you're absolutely right. Your total cost is premium plus variable expenses, and those variable expenses are your actual utilization of the plan. And that's when you start getting into plan design and so on.
Joyce Griggs: One question I just had , because I know you said election and it's once a year and it's open enrollment, and I think we, we've all become accustomed to that being at the end of the year, even if we're, you know, in, in the marketplace, it's the same time of year.
But question about like, what if there's a, an event in my life, like either in the middle of the year I get married, or I have a kid in the middle of the year, or I adopt a kid in the middle of the year. Can I change anything then or no?
Jordan Shields: That's a great question. And, and you can, so the federal HIPAA guidelines create what's called a special election period. So my open enrollment was January. I chose my plan and my wife had a child in June. That change in my family's status actually allows me to go ahead and make a complete change for my family despite the fact that, you know, I knew the child was coming and all that, and I made my decision based on whatever. But maybe things changed or I've got a problem. So within 30 days of the event, I can make a wholesale change to my election, and that's guaranteed under federal law.
Joyce Griggs: That's great. Okay. That's really, really good to know. All right, so what's next? Now that we have these, these two sets of threes under our belt.
Jordan Shields: So now we get into some variables and I hold these variables kind of over here because they're not going to be the driver for your selection, but there are things that you need to consider and I don't wanna leave those unattended. And the three main things are prescription drugs, preventive care, and shopping around.
So even though I'm gonna be talking about scenarios, and here's how I'm gonna make a decision by, you know, plotting out my costs, I talked about, you know, the variable costs a second ago, you still need to know what those variable costs are and how they actually can vary. They, they are not necessarily a set of expenses that I'm absolutely going to have all the time. So I'm gonna touch on these briefly.
On prescription drugs, know that there are three basic kinds, and you're gonna see this in the plan design you're reviewing. There's generic. There's brand name formulary. And there's brand name non-formulary. As you're preparing your information to make a decision as to what plan is best for you, you need to know how to classify the medications you're taking. And just to make it more complicated, some carriers have gotten away from those three categories, and now they're calling 'em category one, category two, and category three drugs. Or they rank them based on cost. So you need to know, number one, what you're taking by name, dosage, and frequency. And then as you look at the carriers that are under consideration for selection, you need to see exactly where those medications that you're looking at are classified. And if you have a choice of a PPO or an HMO, how do they classify each of them? Cause they could be different. And what are you going to be expected to pay, the co-payment? Or is it subject to a separate deductible or something? So you need to know exactly where to put those drugs when you're reviewing plans.
Joyce Griggs: Mm-hmm.
Jordan Shields: And, and there's a lot of variants, you know, within them. So it, it can be pretty complex.
Secondly is preventive care. A lot of people think that if I go to the doctor's office and I see them and just a routine screening, it's covered at a hundred percent. Under the Affordable Care Act, all preventive care is covered at a hundred percent, but is preventive care as defined by various medical boards, medical review committees, various professional associations, and they follow a pretty standard format.
What is non-standard? It's when you have a family history of cervical cancer, let's say, and so you get two pap tests a year. One PAP test is preventive. The other PAP test is diagnos. Or you go in and you have a mammography, and they're looking at it and there's some density and so on, and they say, we want you to come back for another test, or you have a family history of fibrocystic breast disease, something like that. You're going in more often than the standard, even though it's standard for you, and even though the doctor's recommending it, and rightly so. One test is preventive a hundred percent. The next test is diagnostic. So be aware that that can come up if you're going outside the normal pattern of screening and care and so on.
And that's related to the idea of shopping around. It is amazing, and, and I've had these calls, a woman calls me, said, I'm gonna get a mammogram at such and such hospital, and they charged me this much money, and I found out later that I could have gotten it done at this freestanding clinic, and it's 25% of the cost. This is true for MRIs. This is true for mammograms. This can be true for a lot of lab tests. And so on. So when you know you're going to have certain expenses and if you know they're not gonna be covered at a hundred percent, it is a good idea to figure out the best, most cost efficient place to have them. Check with your doctor. If I have the test done here, if I have this thing done here, is that gonna be okay with you? Most times it is, but check with your doctor and then you can again say, okay, this is what I'm gonna have to spend for this.
So these variables I'm talking about, the preventive versus diagnostic, shopping around places to get 'em, and the different classification of drugs are all necessary for you to understand before you finally plug the numbers into the scenarios, which is the last thing we're gonna cover.
Anything I've missed there, Alan?
Alan Feren, M.D.: No. The one thing I would suggest, though, is sometimes if you happen to go outside those preventative guidelines and have a test that's very expensive, like for example, a colonoscopy, that's can be very expensive. Particularly if they found a polyp, let's say, during the initial preventative and you go and have it done somewhere other than in the network, those prices can be negotiable so that you can go and speak with whoever at the hospital or wherever you went to have that particular test and asked to pay the discounted rate that they have with a particular health plan. So MRI is a classic where they're gonna charge, you know, well over a thousand dollars and a typically uh, discounted agreed upon rate is somewhere in the range of maybe a couple hundred dollars. And I think makes good sense to, to not just accept that you're gonna have to pay that amount of money that that you were billed for.
Joyce Griggs: These are great points on costs and on shopping around for costs. This is a great time to actually use search engines because there is more and more transparency in costs, including the cost of surgeries, that that we as consumers now have access to and, and it gives us a lot more power. Cause we've never thought about the cost of these things before. I love all of these suggestions and I thank you for them.
Alan Feren, M.D.: But don't go just because of cost.
Joyce Griggs: Mm-hmm. That's, that's right. But it, but it can be a factor now in our decisions where before —
Alan Feren, M.D.: Oh, absolutely.
Joyce Griggs: — it didn't factor in our decision. It was something that happened to us after the fact.
Jordan Shields: It's know your cost. Just don't go for cost and you're going to need to know all this information for when you're finally sitting down and you're ready to make a decision and look at the different scenarios available to you. Now you have all the information. You can plug in, now I'm ready to figure out where I want to go.
Joyce Griggs: Mm-hmm. I love that. Know your cost, just don't go on cost.
Jordan Shields: Right.
Joyce Griggs: We're gonna remember that one. Okay.
Jordan Shields: And that brings us to the final thing. It's like, now what? Now I have all this information and what decision am I gonna make? So this is where you come to three scenarios.
When you're looking at plan designs, and whether it's small group where you've got platinum, gold, silver, bronze, or the market which use the same designations, or you're working for a large employer where they call their plans, whatever they call their plans, it doesn't matter. The only variables between plans are: the annual deductible; the amount you pay before the carrier kicks in; co-payments for drugs and for office visits; the percentage paid after the deductible; and then to me the most important number is the maximum out-of-pocket cost or the out-of-pocket limit, or the maximum liability or the co-payment maximum, whatever they call it. It's, what's my bottom line? If I have a million dollar claim, what's it gonna cost me for the calendar year? Almost every plan, almost every plan is on a calendar year basis. There are some rare plans. We actually have a client that has one where the deductible and everything is on a fiscal year or a plan year basis, but 98 times out of a hundred it's calendar year that you're looking at.
So, as you look at the different plans, those are the only variables you really need to consider: deductible, co-payments, percentage, out-of-pocket limit. And that's gonna help you make your decision.
You are looking at three basic scenarios. Everybody has three scenarios in their life. Worst case. Best case. And your case.
Worst case is I get hit by a bus or, I'll give you my case, I've got a total knee replacement coming up in a couple months. It's gonna require at least one night in the hospital. In my case, it might require two cause I've got some preexisting medical situations. So I'm gonna be in the hospital for two days. I can already tell you this is a worst case scenario. It's gonna cost at least 60 or $70,000 guaranteed. So the only thing I care about when I'm choosing a plan for 2023 is what's the most it's going to cost me? As I look at the different plans, this plan will cost this much. This plan will cost that much. This plan will cost this much. And I would want to choose the plan that has the lowest liability limit. Maybe, maybe. Because then the second thing is we go back to the information we have before. What's my premium? So how much am I paying for these different plans with these different variabilities?
So as an example, let's just say that one plan is gonna save me a thousand dollars versus another plan because it has a lower liability limit, but it's gonna cost me $1,500 more in premium. It makes no sense to spend $1,500 to get a thousand dollars back. So as I walk clients through these scenarios, we plot out the numbers.
Worst case, what's your best choice? And maybe that's all they care about. It's all I care about personally.
Over to best case. I'm perfectly healthy. I'm not gonna have anything done during the year except maybe a checkup. I'm positive. I'm 25 years old. I'm indestructible. Everything's cool. What plan should I choose? Choose the cheapest plan because they all cover preventive care at a hundred percent in the small group and individual market. If you're working for a large employer, they probably pay a hundred percent proof of preventive care, but just make sure you know. And then choose the cheapest plan for that year.
And then we get into your case. I take this drug, I see this doctor, I do this thing. I need a mammogram twice a year. I need a PAP test twice a year. Whatever my variables are. And you look at those expenses you're gonna expect to pay or those services you expect to receive, and you look at how much you're gonna get reimbursed for each of those services with each of the plans under consideration. You go down the list. Here's how much it's gonna cost me into this. Here's how much it's gonna cost me into that. How much am I paying for each plan? And I weigh my variable cost versus my fixed cost and say, this is the most efficient plan for me.
That sounds really simple. It is really simple. When you've done it a couple thousand times. When you're doing it for the first time, again, it's still just going right down the chart. How much for here? How much there? Column A, column B, bop, bop, bop, bop, bop. Cost and cost. It's really that simple. And remember, again, I can't say this enough, just for this year. Just for this year. That's the decision you make.
And it may be a very minor difference, in which case, eh, maybe you, you choose a plan that looks a little better. But again, worst case. Best case. Your case. Make your decision based on that and all the other variables we were talking about before. And then you're done for the year.
Joyce Griggs: Love it. I love it. I just wanna ask you, cause I wanna make sure I understand because I think the audience and I are kind of on the same level here. When I'm putting together my list of costs, like in terms of the premiums, the copays, the deductibles, the out-of-pocket limit, whatever they call it, every plan calls it something different, and then of course, all of my costs that I know of, right? If I have type one diabetes, I know how much I'm spending on insulin and all the other things, or if I'm taking other drugs, what medicines am I taking? And then I wanna look to see what category they are right within the plan. Because like you were saying before, I could be paying a very different price, depending on how the plan categorizes and deems that they're gonna pay.
Jordan Shields: That's why when you take the scenario, as you say, I've got these six things, here's plan A.
Plan A has co-payments of $10 for an office visit. I know I'm gonna have six office visits of the year. 60 bucks. Plan B is $20 for an office visit, six visits, 120 bucks. Clearly, Plan A is in the lead looking better than Plan B, and now I'm looking at the deductible. I know I'm gonna have to go in for something that the deductible's gonna be charged. This is 250. This is 500. The test I'm considering is gonna be a thousand dollars. Plan A is in the lead again, it's ahead by 250 bucks. And then I've got this one generic for 10 bucks, and I've got this one brand name for 25 versus 20 and 45. Plan A is in the lead, so at the end Plan A wins by $400.
But Plan A costs $500 more than Plan B. Yeah. Again, why am I spending $500 to get $400 back? So that's why we measure it all out. Look to see which plan is better. And this difference, this delta has to exceed the additional premium you pay for the better plan. And if it doesn't then you go for the lesser plan. Because it's all about how much you're gonna pay at the end of the year. What's my total cost for the year. But to your point, Joyce, hey, I've got all these things. Plug it in. Plug it in. Look at the total, compare it to the premium, make your decision. Simple.
Joyce Griggs: Mm-hmm.
Alan Feren, M.D.: For those who are a little bit challenged by math, HMOs tend, in general, to be lower cost and for young people, and certainly for young families, HMOs really offer a good bargain price for healthcare. Plus there are no forms that you need to fill out and you're not gonna be paying bills which you may be paying for with other types of healthcare. So it's just a good general thing to think about if you have a young family or if you're single and indestructible as Jordan said, as most uh, teenagers and young adults are.
Jordan Shields: Even some older adults think they're indestructible too, but enough about me.
Then there's the convenience factor as well. I mean, in my own family, you know, I want to have a personal choice of physicians because I do have some ongoing medical situations, but I'm also raising my great-grandchildren, lucky me, and, you know, they're eight and ten. Their needs are a whole lot different than mine, as in they don't have any, so they actually have a separate plan than I do because I choose my plans individually. So they have Kaiser. Kaiser's great with pediatrics. It's like a mile down the road. It's easy to, you know, to see them and get there and all that. Bing, bang, boom, they're in, they're out. Life is beautiful. My life is simple. It's convenient. Great. And the out-of-pocket expense is minimal. I, on the other hand, you know, keep having surgeries and various other things. So, I mean, I have my own personal orthopedist. So when you, when you've got somebody that's, you know, sending you Christmas cards, Hey, we haven't seen you in the hospital for a while, when are we gonna see you again? That's a little different relationship, one that I wish to keep until they retire, and then hopefully I'll be done with all my surgeries.
Joyce Griggs: It's is a really good point that you bring up. You know, I hadn't thought about this. When we're employed, we're conditioned that you pick what your employer has and the whole family goes on to whatever plan it is that you choose. Everybody has to go on to the same plan.
Jordan Shields: Right.
Joyce Griggs: Now if you're in the marketplace, is it different based on what you just said? If my child has different needs than I do, can I make a different choice? And is that to my benefit?
Jordan Shields: You can. You can, and I do, but that's because I'm looking at individual plans myself anyway. And my wife has Medicare, so I mean, we have a very complicated situation.
However, if I'm with an employer and I put my children under my plan as dependents, I get a tax benefit. Even if my employer's not paying for my dependents, I still am paying for the dependents on a pre-tax or tax exempt basis. When I go to the marketplace or just to an individual carrier, you know, like Kaiser, now I'm paying with after-tax dollars, which is yet another factor. But it's a great point and it's a good question. And so as we talk about it, I say, well, you could put your kids on a completely separate plan individually, and then the person will say, well, is that a good idea? Say, well, let's work out the numbers. And now we get into tax numbers. And we figured that out. So it's yet another variable you can plug in.
Joyce Griggs: Okay.
Jordan Shields: But in my case, this is better for me and I was willing to pay more money to do it that way because it's so much of a convenience for me, and I'm willing to pay for the convenience.
Joyce Griggs: This is amazing. So should we just do a wrap up then, a summary of what we have to take into consideration.
Jordan Shields: If you have an employer that usually are pretty good at being able to help you break it down. If not, then there's usually a broker that can help you break it down, which is what I do.
But the main thing that if you don't have those resources available to you is you need to know your medical expectations. You need to know the costs associated with those expectations. Plug in the cost of those expectations into the different plan designs you have available. And then once you've done that and you've got your basic cost stuff down, then you play the scenario game.
Worst case, the only thing I care about is the big one. Best case, I don't care about anything cuz I'm not gonna use anybody or see anybody. And your case where you plug it in on different designs. So if you could remember to get your material ready and then plug it in and then weigh that against the final premium paid, you should be good to go. It'll be the right decision for you.
Joyce Griggs: That's amazing. Alan, anything to add on that before we sign off?
Alan Feren, M.D.: The only thing I would add is that I think choice plays a, a big role in this, too. The cost is certainly a, a major driver, but I think that choice for some individuals, particularly if they are financially able to pay for that choice, it may make sense for them.
Joyce Griggs: Excellent. Thank you so much, Dr. Alan Feren and Jordan Shields, our experts on insurance. Always amazing to talk with you. Thank you so much.
Jordan Shields: Thank you.
Alan Feren, M.D.: Thank you.
Joyce Griggs: Thank you so much for watching, and before you go, please check out our blog. There's many detailed blog posts for you to check out there on this topic and others that will be important to you as you navigate through your healthcare. And if you haven't already, please subscribe because you will get on a regular basis in your inbox a knowledgeable friend who's gonna make it easier and simpler for you to deal with all of your healthcare needs. Also we have a resources page that's full of free and very important resources that you can take advantage of. So check out the blog, subscribe to our content, and check out the free resources page. Thanks again for watching. I'm Joyce Griggs for United States of Healthcare.