Brokers' 7 tips for navigating Covered California in the run-up to Dec. 23

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The countdown is on. For those who want insurance coverage by Jan.1, Monday is the last day to sign up. Figuring out all your options and deciphering insurance speak while doing the last-minute enrollment shuffle can leave you wanting to yank your hair out.

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But, there’s really no need, says broker Susie Fabrocini of Reseda - one of the more than 8,800 licensed insurance brokers statewide certified to sell plans through the state-run marketplace, Covered California.

"Every time I talk to a group of people and tell them that I can...guide them and...show them how to fill out an application, they're always surprised," she says. "They had no idea that there were agents involved that they could go to for help."

It was only this month that Covered California really began using the "B" word. Until then, there was little official comment about brokers, who charge consumers nothing to guide them through the befuddling task of buying insurance. (Brokers get paid - as they always have - through commissions from the insurance companies, whether they sell plans through Covered California or directly through the company.) 

As the clock ticks toward December 23rd, the line to buy insurance is getting increasingly long. 

Covered California said on Thursday that from Monday to Wednesday, more than 53,000 people enrolled in a health plan. Only 30,000 signed up in the entire month of October. 

"I would allow at least an hour to enroll online," says Fountain Valley insurance broker Tom Freker. "The (Covered California) system is just completely overloaded. The phone is even worse."

So what's a consumer to do in these final hours? We asked the pros and got these seven tips: 

1. Get help.  As of this week, Covered California officials report there are: 

  •  8,849  brokers certified to sell plans on and off the Covered California marketplace (and there are another 10,153 licensed insurance brokers presently undergoing certification through Covered California);
  • 2,565 certified enrollment counselors who can help help you with plans sold through Covered California (and 3,871 currently in training);
  • more than 10,000 county workers who can enroll qualified Californians in Medi-Cal and in plans sold through Covered California. 

2. Find out if you qualify for financial assistance. You can quickly figure this out by logging onto Covered California and then clicking on the "Shop and Compare" link that's on the homepage. Plug in the number of people in your household; your household income; your zip code;  and the age of each adult, and you'll find out immediately whether you qualify for subsidies, and if so, how much they are.

 If you do qualify, you'll only get to claim the discounts if you buy a plan through the Covered California marketplace. If you don't qualify, you might want to stick around for a bit and shop on the site.  Covered California's website offers  a side-by-side list of plans and prices that makes comparison shopping a bit easier.  Once you choose a plan, you can opt to sign up directly with the insurance company.

3. Know your subsidies. Discounts come in two flavors. The first type: tax credits to offset the price of your monthly premium. Those are available to individuals earning up to about $46,000 a year, and to a  family of  four earning about $94,000 a year. The second variety: cost-sharing subsidies. They reduce co-pays, co-insurance and deductibles for individuals with annual incomes of about $29,000 a year and families of four who earn up to $59,000. But they are only available to those who purchase a silver plan through Covered California. 

4. Know your comfort level.  Would you prefer a lower monthly premium payment for you health insurance policy and higher out-of-pocket costs when you seek care? If so, a high deductible  bronze or silver plan may be most appealing to you. But if you have prescriptions and a regular need for lab tests and/or doctor visits, consider a gold or platinum plan, brokers say. The premium is higher every month, but you'll more than make up for it with lower co-pays, lower co-insurance and lower deductible costs. 

"Every client has their own insurance needs," Freker says. "Someone who is very ill would obviously benefit from the higher levels of coverage and they have to weigh that against the premium."

5. Know the difference among a PPO, an HMO, and an EPO. Brokers say there's no need to get panicked by this alphabet soup of insurance speak. Here are the basics:

  • PPO - Preferred Provider Network: PPOs offer the biggest networks and the most freedom of choice. You can even leave the network and get some reimbursement (usually 50 percent) for care you seek from an out-of-network provider.  If you want to see a specialist, there's no need to check in with your primary care doctor. You're in charge. 
  • HMO - Health Management Organization: These are the most restrictive policies. You'll be assigned a primary care doctor who will coordinate your care. That means you'll first need a referral from him or her before seeing a specialist. What's more, if you venture outside the network for care, you'll get zero help paying the bill. It's all out of your pocket.
  • EPO - Exclusive Provider Organization: These are essentially PPO-HMO hybrids. They allow you the same freedom within the network of providers as does a PPO. But the network is smaller. What's more, like an HMO, you'll get no help paying for a provider who is outside the EPO plan.   "Also with an EPO there will be no out of state benefits unless there is a legitimate emergency," Gordon says. 

6. Check out the provider network.  This is easier said than done. Most companies are in the midst of renegotiating contracts with health care providers, leaving the networks in a state of flux. So if you have a particular doctor you prefer, contact her office directly to confirm whether she's participating in the plan you like. 

7. Take a breath, you still have time.  While Dec. 23 marks the deadline to purchase plans that take effect on Jan. 1, you still have until March 31 to buy insurance without facing a tax penalty under the Affordable Care Act. 

 

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