Get Smart About Your Plan

Confused by your insurance options this year, especially now that Congress is getting in on the act? Staff Writer David S. Hilzenrath offers answers for some of the most pressing questions.

Q. If my employer offers multiple options, how should I assess them?

First, take the time to study your choices. Even if you like your current plan, don't assume it will stay the same next year, says Nancy Metcalf, an editor at Consumer Reports.

Look beyond the premium at features that affect both the value of the coverage and its affordability. Are the doctors and hospitals you favor in the insurer's network? How much would you pay out of pocket for office visits, hospital stays and drugs? Find out how each plan would handle any medications you take regularly.

Note the difference between co-payments, which are fixed amounts you pay out of pocket for certain items, and coinsurance, which requires you to pay a percentage of the bill. (There's a potentially huge difference between a $20 co-payment and a 20 percent coinsurance charge.)

What services, if any, require advance approval by the health plan?

Are there annual or lifetime limits on what the health plans would pay? Are there limits on what you could be required to pay? Are any expenses excluded from such limits? For example, do co-payments and deductibles count toward your out-of-pocket limits?

Figure out how the competing plans would cover any predictable medical needs, but don't stop there. Game out what would happen if you suffered a catastrophic illness or injury and suddenly required hundreds of thousands of dollars of coverage.

Q. If premiums are rising and I'm healthy, does it make sense to try buying insurance in the private market instead of through my job?

Almost never, experts say.

If you take the coverage your employer offers, there's a good chance your employer will pay most of the premium. This year, on average, employees are responsible for only 17 percent of the premium for single coverage and 27 percent of the premium for family coverage, according to a survey by the Kaiser Family Foundation and the Health Research & Educational Trust. That means that for average family coverage, employers are contributing $9,860 of the $13,375 annual premium, and for average single coverage, employers foot $4,045 of the $4,824 tab. If you buy your own coverage, you'd be forfeiting that benefit.

Before you pass up the chance to enroll in employer-sponsored coverage for the coming year, make sure you actually qualify for individual coverage. Even if you think you're in good health, insurers may find grounds to reject you.

Q. If I buy insurance on my own, what should I watch out for?