12 Tips to Get Your Best Health Care in 2016

The Supreme Court upheld the health care law last summer, but there are still lots of surprises waiting for you during open enrollment this fall.

W hen Julie Thiets heard that the Supreme Court had upheld the Affordable Care Act’s federal subsidies in the landmark case King v. Burwell this summer, she screamed with relief.

“I felt like I’d won the lottery!” she says. The Decatur, Ga., video services provider is just one of the roughly 8 million people nationwide who need the subsidies to buy health insurance through the insurance marketplace established by the 2010 health care law. “Without that insurance, my rheumatoid arthritis bills would have wiped us out,” she says. “My husband and I would have lost our business and our home.”

After subsidies (largely tax credits based on income or circumstances), more than two-thirds of those Americans—including Thiets and her husband—will pay less than $100 a month in premiums for insurance. As President Barack Obama has said, “It may end up costing less than your cable bill or your cell phone bill.”

That’s the good news. As we head into open enrollment, not all of this year’s surprises are as positive. Did you know, for instance, that an employer can stop covering employee spouses? Or that if you’re enrolling in Medicare for the first time you may be hit with premiums 52 percent higher than what current beneficiaries pay?

Despite the twists and turns, if you understand your options and shop wisely, experts say you can find your best health insurance for 2016, and maybe save money too.

“More than ever,” says Craig Rosenberg, Aon Hewitt benefits consultant, “this is the year for shopping.” Here’s what you need to know before you seal the deal.

1. Your employer may pay for you to have surgery overseas.

A small but growing number of self-insured companies of all sizes will offer their employees the option of having major operations, such as heart bypass surgery and hip or knee replacements, at vetted hospitals overseas—from Puerto Rico to Thailand, says Joe Harkins of the Medical Tourism Association. Close to 1 million Americans leave the country for medical care every year.

“My wife thought I was crazy,” says Wayne Wright of Marshall, Texas. But he went ahead with a double knee replacement in the Cayman Islands in March under a medical travel option offered by his employer—and saved more than $6,000. “I didn’t pay a penny out of pocket, including airfare and the resort hotel,” he says. “We got treated like royalty. And my knees feel great.”

Why are employers going this route? Even after covering all medical costs, travel and sometimes offering a bonus, companies can end up paying only half of what it would cost for the employee to have the procedure in the U.S.

2. Your company could link up with a big-name hospital for better coverage and savings.

Major corporations, including Lowe’s, Walmart and Boeing, have struck deals with the prestigious Cleveland Clinic to allow workers to have cardiac procedures there at little to no cost. The companies get discounts of up to 40 percent off the hospital's prevailing rates, and the employees (many of whom are within driving distance of the hospitals) are often back at work sooner with fewer complications. PepsiCo and others have similar arrangements for various procedures with Johns Hopkins, Mayo Clinic and other top hospitals, which benefit from the higher volume of patients.

3. Your company may give you money to buy your own insurance.

Some companies with 50 employees or less may drop their group health coverage for 2016 and instead give their workers “raises” to help them buy “Obamacare” insurance on the online public exchanges at healthcare.gov/get-coverage. Is it a good deal? Some of those workers will come out ahead, thanks to Obamacare’s generous federal subsidies. After subsidies, many individuals making up to $46,640 and families of four earning up to $95,400 will get more comprehensive coverage for less.

On the other hand, some big corporations are also opting to drop their group plans and instead contract with insurance companies to set up “private exchanges.” These employers will then give their workers a lump sum to buy their own health insurance online from these exchanges, run by benefits consulting companies like Aon Hewitt and Mercer. Employers save by capping how much they spend subsidizing their workers’ health care. Employees also can save by choosing less expensive coverage with higher deductibles—but they then run the risk of getting hit with ruinous medical bills if they get sick.

What’s more, because the private exchanges still offer coverage that meets Affordable Care Act standards, these workers don’t qualify for federal subsidies to buy Obamacare on the public exchange.

“Instead of providing a pretty secure boat, these companies are offering workers life vests to weather the health care storms on their own,” says Consumer Watchdog president Jamie Court.

4. You may end up with a health savings account (HSA)— and a pile of doctor bills.

More companies also are shifting workers from their standard group health coverage to health savings accounts, a portable medical savings account that you can contribute to tax-free. According to Rosenberg, 16 percent of companies surveyed by Aon Hewitt will provide tax-advantaged HSAs as their only insurance option in 2016. And many companies still offering group health plans will try to entice workers to switch to HSAs by offering bonuses of $1,000 or more.

But don’t jump into this option. Before you can open an HSA, you must enroll in a high-deductible health plan. If you’re young, well paid and stay healthy, you can sock away thousands for years. But if you get sick, your out-of-pocket expenses could soar to $10,000 or more, wiping out your HSA savings—if not your entire bank account.

Medical bills remain the leading cause of personal bankruptcies. As long as you have a choice, you should stick with traditional group health coverage.

5. Family members may have to get their own insurance.

More companies will refuse to cover spouses who are eligible for health insurance elsewhere. Of those who continue to offer spousal coverage, around one in 10 will impose “unitized pricing,” which will force workers to pay more for each dependent than they do under a

typical family plan. Workers currently paying $400 a month under a family plan might be charged $450 if they get “unitized” in 2016.

6. New beneficiaries may pay more for Medicare.

Social Security payments will not increase next year, so Medicare beneficiaries who pay their Part B doctor premiums through their Social Security deductions won't pay a penny more. But the rest—about 30 percent—will get socked with increases of up to 52 percent, raising their premiums to $159.30, rather than the current $104.90. That group includes the 3.6 million newly eligible beneficiaries. Because half of all Medicare beneficiaries live on less than $23,500 a year, Medicare Rights Center president Joe Baker says he’s hoping Secretary of Health and Human Services Sylvia Mathews Burwell will adjust the rates at the last minute. If you're struggling with health costs, call 800-Medicare and ask about the Medicare Savings Program. Only one-third of those eligible for the program's assistance are actually enrolled.

7. Your company may impose stringent spending caps. Well over 10 percent of companies will cap the amounts they pay for anything from MRIs to serious procedures like bariatric surgery for weight loss, according to the Employee Benefit Research Institute. The caps may force workers to shop for less expensive providers. If this happens to you, ask if your company has contracted with a patient advocate service for help shopping around. (Many do.) Milwaukee-based Patient Care, for example, identifies at least three quality options for workers.

8. Medicare Part D enrollees should shop around.

Many Part D beneficiaries would lower their premiums by changing plans each year, since prescription insurers constantly shuffle drugs on and off their lists of approved drugs, or ratchet up the cost of specialty medicines. But only about 10 percent of beneficiaries actually switch. Do yourself a favor: Go to medicare.gov to find your best Part D plan for 2016 with the Medicare Plan Finder.

9. Your insurance may require you to try cheaper drugs first.

Increasingly insurers are looking for ways to control the expense of specialty drugs for cancer, rare hereditary illnesses and chronic conditions. Such drugs can cost upwards of $100,000 a year per patient. The key words to look for in a plan are “step therapy.” Step therapy means that if you get sick,

you and your doctor will need to get prior approval for high-priced drugs from the insurer’s staff doctors—and you may be required to try older, less expensive treatments first. “You don’t want to be required to suffer getting sicker before you get the cure,” says employee benefits advisor Russ Blakely.

Be sure to read the policy coverage carefully!

10. Obamacare may be a better option than COBRA.

For 30 years, millions of laid-off workers were thankful to have COBRA continuation health coverage, which allowed them to keep their old employer’s insurance for more than a year— though at very high, unsubsidized prices. But now experts say many COBRA candidates will be better off with Obamacare, especially if their reduced incomes qualify them for the federal subsidies the Supreme Court upheld this summer. Even better, you don’t have to wait for the open enrollment period. Getting laid off makes you immediately eligible to apply for Obamacare coverage—as well as the law’s premium and cost-sharing subsidies.

11. You need to shop around even if you love your Obamacare plan.

On average, Obamacare monthly premiums will increase by a moderate 4 percent nationally. But rates in different states could vary widely. For example, New York’s 17 insurers will get a 7.1 percent increase on average. Established Oxford Health Plans is reducing its premiums by 12.3 percent. But Health Republic Insurance, a new nonprofit cooperative, is raising rates 14 percent after losing millions when five times as many people as expected enrolled in their plan last year. Even if you love your current Obamacare plan, experts suggest that you shop healthcare.gov/ marketplace carefully for your best deal in 2016.

12. Medicare Advantage Plans may not be the best deal.

More than 30 percent of Medicare beneficiaries are enrolled in private Advantage Plans from insurers like Humana and Aetna, rather than in the government’s Original Medicare. Typically Advantage Plans feature low premiums, all-in-one medical and drug coverage and extras like gym memberships and 24-hour nurse lines, which make them quite popular. But many Advantage Plans have limited provider networks concentrated in one geographic area—and reserve the right to shed doctors and hospitals after you’ve signed up.

“It can be like paying for a car and getting a bicycle,” says Judith Stein at the Center for Medicare Advocacy. You may pay higher premiums for Original Medicare than you would for an Advantage Plan, she says, but you’d be covered at virtually every hospital and at about 90 percent of doctors nationwide.

Frank Lalli, The Health Care Detective™, is writing a book for Simon & Schuster on how to find affordable health care.