Planning Navigator

Your Guide to Develop Your Healthcare Personal/Family Planner

Table of Contents

Introduction

Section I:  WHAT ARE: Basic Healthcare Questions

Section II:  HOW TO: Determine your “Healthcare Must Haves”

Section III: HOW TO: SELECT YOUR HEALTH INSURANCE PLAN

Step IV:  HOW TO: SELECT A HEALTHCARE SPENDING ACCOUNT (HSA) OR FLEX SPENDING ACCOUNT (FSA)

Step V: HOW TO: SELECT YOUR HEALTHCARE PROVIDERS

Step VI: HOW TO: DELOP A HEALTHCARE BUDGET

Introduction

Healthcare consumers rarely think or plan about their healthcare.  Consumers spend more time planning for a family vacation than they do healthcare.  The Personal/Family Health Planner is a document that guides the healthcare consumer to develop an annual medical and financial plan.

Healthcare medical and financial events, planned or not planned, can be devastating to an individual or family.  At a minimum, your Personal/Family Health Plan can plan for expected healthcare events, such a new baby, surgical procedure to fix your hip, etc….  In addition, your Personal/Family Health Plan can take into account any chronic health conditions that currently exist and your age.  The older you are, the likelihood exists you will have more medical problems.

Planning for your healthcare annually can be very daunting.  As the healthcare landscape changes, this process will become very important.  Today’s healthcare consumer has been delegated the responsibility to manage their healthcare.  The goal is to help the consumer with a practical approach to plan for their healthcare. The following steps will start the process.

Section I:  Basic Healthcare Questions

The first step is to determine you and your family’s current health status.  Current health status is based on previous health conditions, any current chronic conditions, your age and any other medical condition that exists.  For those healthcare consumers that have children, in addition to the above, add any pediatric care needed if appropriate.

Section II:  Determining your “Healthcare Must Haves”

“Healthcare Must Haves” are the foundation for your annual Personal/Family Health Plan.  “Healthcare Must Haves” are defined in two general categories: Medical and Financial.  The following guide will start with the basics.

Medical

Questions Comments
Are you planning a family?
Are planning any elective surgeries?
Do have a chronic/reoccurring medical condition?

If you have answered yes to any of the above, start to plan for these medical events.  Planning starts with reviewing your current health insurance plan to determine the coverage.  If you are in a new health insurance selection period, review all plans available to determine coverage compared to monthly premiums.  Out of pocket expense is a very big consideration.  Make sure you understand your financial responsibilities.  Step IV will help with this process

Financial

Questions Comments
Are all healthcare providers in network; PCP, etc…?
Can you afford the annual out of pocket expense?
Can you afford the monthly premiums?

Financial considerations are based on your current health insurance plan or the health insurance plan you have selected.

Section III: SELECTING YOUR HEALTH INSURANCE PLAN

Here’s a quick recap before you get into the details:

  1. Go to your online health insurance marketplace and view all of your plan options.
  2. Decide which type of health insurance plan — HMO, PPO, EPO or POS — is best for you and your family, and whether you want an HSA-eligible plan.
  3. Eliminate plans that exclude your preferred doctor or that don’t have local doctors in the provider network.
  4. Determine whether you want more health coverage and higher premiums, or lower premiums and higher-out-of-pocket costs.
  5. Make sure any plan you choose will pay for your regular and necessary care, like prescriptions and specialists.

Step 1: Choose your health insurance marketplace

How you shop for health insurance will depend on what’s available to you.

If your employer offers health insurance

Most people with health insurance get it through an employer. If your employer offers health insurance, you won’t need to use the government insurance exchanges or marketplaces, unless you want to look for an alternative plan. But plans in the marketplace are likely to cost more than plans offered by employers. This is because most employers pay a portion of workers’ insurance premiums.

If your employer doesn’t offer health insurance

Shop your state’s online marketplace, if available, or the federal marketplace to find the plan that’s best for you. Start by going to HealthCare.gov and entering your ZIP code. You’ll be sent to your state’s exchange, if there is one. Otherwise, you’ll use the federal marketplace.

You can also purchase health insurance through a private exchange or directly from an insurer. If you choose these options, you won’t be eligible for premium tax credits, which are income-based discounts on your monthly premiums.

Step 2: Compare types of health insurance plans

You’ll encounter some alphabet soup while shopping for the best health insurance plan. The most common types of health insurance policies are HMOs, PPOs, EPOs and POS plans. What you choose will help determine your out-of-pocket costs and which doctors you can see.

Comparing health insurance plans: HMO vs. PPO vs. EPO vs. POS

Plan type Do you have to stay in-network to get coverage? Do procedures & specialists require a referral? Snapshot:
HMO: health maintenance organization Yes, except for emergencies. Yes, typically. Lower out-of-pocket costs and a primary doctor who coordinates your care for you, but less freedom to choose providers.
PPO: preferred provider organization No, but in-network care is less expensive. No. More provider options and no required referrals, but higher out-of-pocket costs.
EPO: exclusive provider organization Yes, except for emergencies. No, typically. Lower out-of-pocket costs and usually no required referrals, but less freedom to choose providers.
POS: point of service plan No, but in-network care is less expensive. Yes. More provider options and a primary doctor who coordinates your care for you, with referrals required.

Look for a summary of benefits

Online marketplaces usually provide a link to the summary of benefits, which explains all the plan’s costs and coverages. A provider directory, which lists the doctors and clinics that participate in the plan’s network, should also be available. If you’re going through an employer, ask your workplace benefits administrator for the summary of benefits.

Weigh your family’s medical needs

Look at the amount and type of treatment you’ve received in the past. Though it’s impossible to predict every medical expense, being aware of trends can help you make an informed decision.

Consider whether you want a referral system of care

Plans that require referrals

If you choose an HMO or POS plan, which require referrals, you typically must see a primary care physician before scheduling a procedure or visiting a specialist. Because of this requirement, many people prefer other plans. However, by limiting your choices to providers they’ve contracted with, HMOs do tend to be the cheapest type of health plan.

A benefit of HMO and POS plans is that there’s one primary doctor managing your overall medical care, which can result in greater familiarity with your needs and continuity of medical records. If you do choose a POS plan and go out-of-network, make sure to get the referral from your doctor ahead of time to reduce out-of-pocket costs. (You cannot go out-of-network with an HMO unless it’s an emergency.)

Plans that don’t require referrals

If you would rather see specialists without a referral, you might be happier with an EPO or a PPO. (EPOs typically don’t require a referral, but some do, so read the fine print.) An EPO may help keep costs low as long as you find providers in-network; this is more likely to be the case in a larger metro area. A PPO might be better if you live in a remote or rural area with limited access to doctors and care, as you may be forced to go out-of-network.

What about an HDHP with a health savings account?

A high-deductible health plan, or HDHP, can be any one of the types of health insurance above — HMO, PPO, EPO or POS — but follows certain rules in order to be “HSA-eligible.” These HDHPs typically have lower premiums, but you pay higher out-of-pocket costs, especially at first. They’re the only plans that qualify you to open a health savings account, or HSA, which is a tax-advantaged account you can use to pay health care costs. If you’re interested in this arrangement, be sure to learn the ins and outs of HSAs and HDHPs first.

» MORE: HSA vs. FSA: Differences and how to choose

Step 3: Compare health plan networks

Your health insurance “network” refers to the medical providers and facilities your health plan has contracted with to provide your care.

Why does the network matter?

Costs are lower when you go to an in-network doctor because insurance companies negotiate lower rates with in-network providers. When you go out-of-network, those doctors don’t have agreed-upon rates, and you’re typically on the hook for a higher portion of the cost.

Do you have preferred doctors?

If you want to keep seeing your current medical providers, make sure they’re in the provider directories for the plan you’re considering. You can also ask your doctors directly if they take a particular health plan.

Is a large network important?

If you don’t have a preferred doctor, it’s probably a good idea to look for a plan with a large network so you have more choices. A larger network is especially important if you live in a rural community, since it’ll give you better odds of finding a local doctor who takes your plan.

Eliminate any plans that don’t have local in-network doctors, if possible; you may also want to eliminate those that have very few provider options compared with other plans.

Step 4: Compare out-of-pocket costs

Out-of-pocket costs (that is, costs other than your monthly premium) are another key consideration. A plan’s summary of benefits should clearly lay out how much you’ll have to pay out of pocket for services. The federal online marketplace offers snapshots of these costs for comparison, as do many state marketplaces.

Know your health insurance terms

It’s useful to know the definitions of some key health insurance terms:

  • Copay: This is a flat fee (such as $20) that you pay each time you receive a health care service or procedure.
  • Coinsurance: This is the percentage (such as 20%) of a medical charge that you pay; the rest is covered by your health insurance plan.
  • Deductible: This is the amount you pay for covered medical care before your insurance starts paying.
  • Out-of-pocket maximum: This is the most you’ll pay in one year, out of your own pocket, for covered health care. Once you reach this maximum, your insurance pays the rest.
  • Out-of-pocket costs: These are all costs above a plan’s premium that you must pay, including copays, coinsurance and deductibles.
  • Premium: This is the monthly amount you pay for your health insurance plan.

» MORE: Understanding copays, coinsurance and deductibles

Higher premiums, more coverage

In general, the higher your premium, the lower your out-of-pocket costs such as copays and coinsurance (and vice versa). A plan that pays a higher portion of your medical costs, but has higher monthly premiums, may be better if:

  • You see a primary physician or a specialist frequently.
  • You frequently need emergency care.
  • You take expensive or brand-name medications on a regular basis.
  • You’re expecting a baby, plan to have a baby or have small children.
  • You have a planned surgery coming up.
  • You’ve been diagnosed with a chronic condition such as diabetes or cancer.

Lower premiums, higher out-of-pocket

A plan with higher out-of-pocket costs and lower monthly premiums might be the better choice if:

  • You can’t afford the higher monthly premiums for a plan with lower out-of-pocket costs.
  • You’re in good health and rarely see a doctor.

» MORE: What is a copay?

Step 5: Compare benefits

By this step, you’ll likely have your options narrowed down to just a few plans. Here are some things to consider next:

Check the scope of services

Go back to that summary of benefits to see if any of the plans cover a wider scope of services. Some may have better coverage for things like physical therapy, fertility treatments or mental health care, while others might have better emergency coverage.

If you skip this quick but important step, you could miss out on a plan that’s much better suited to you and your family.

Address any lingering questions

In some cases, calling the plans’ customer service line may be the best way to get your questions answered. Write your questions down ahead of time and have a pen or electronic device handy to record the answers.

Here are some examples of what you could ask:

  • I take a specific medication. How is that medication covered under this plan?
  • Which drugs for my condition are covered under this plan?
  • What maternity services are covered?
  • What happens if I get sick while traveling abroad?
  • How do I get started signing up, and what documents will I need?

Step IV:  SELECTING A HEALTHCARE SPENDING ACCOUNT (HSA) OR FLEX SPENDING ACCOUNT (FSA)

Informed consumers have several options to help them offset their out of pocket healthcare expense.  Selecting the correct health benefit can be confusing and requires the consumer to understand the differences before making a decision.  Employers who offer health insurance allow healthcare consumers to set up either a FSA or a HSA to cover “qualified expenses” to include deductibles, co pays, co-insurance and prescriptions expenses. Some employers will either contribute monies or match employee contributions to FSA or HSA. Both health benefits have tax benefits, although they are not the same.

The following tables will help the consumer understand the differences between FSA and HSA, qualified and non-qualified expenses, how to estimate your contribution and why use this benefit.

Comparing HSA and FSA

  Health Spending Accounts (HSA) Flexible Spending Accounts (FSA)
Am I Eligible? Having a High Deducible Health Plan; $1,300 for an individual; $2,600 for a family No eligibility requirement
How much can I contribute? $3,350 for an individual; $6,650 for a family.  If you are 55 and older, add $1,000 to each category above Capped at $2,550 for you contribution.  If your employer contributes to your FSA, the contribution will not affect yours
Can I change my contribution amount? Yes, during anytime in the year No, only at open enrollment or with a change in employment or family status
Can I roll over my HSA or FSA at year end? Yes, you can roll over unused amounts to the next year There are exceptions; it is usually a “use it or lose it” and you forfeit any unused balance. A new regulation went into effect in 2014 that employers can offer employees a $500 rollover option.

 

What happens if I change employers? The HAS can follow you if you change employers In many cases, you lose the FSA with an employment change.  There are exceptions such as if you are eligible for a FSA continuation though COBRA
What are my tax advantages? HSA contributions are tax deductible, but can also be deducted from you pay pretax.  Growth and distributions are tax free. FSA contributions are pretax and distributions are untaxed.


General Information about HSA or FSA

  1. The plan may issue you a debit card to use when paying for medical expense. Remember…..it is easy to forget to bring the debit card with you when you have a qualified medical expense.  Planning is critical to insure you are maximizing the benefit.
  2. When using debt card, always make sure you are maintaining all receipts. Some plans will audit plan participants.
  3. The plan may require you to secure certain documentation to support the medical expense, i.e. doctor prescription, a letter from the doctor to document your condition, etc.…..
  4. You may be required to submit a claim form to be reimbursed for the medical expenses
  5. Always secure a list of Qualified Medical Expenses from you plan Administrator at the start of your benefit year
  6. Always determine if you need documentation to support the reimbursement. You can secure the information and process from your Plan Administrator
  7. For those consumers who have a FSA, make sure you have used the total amount prior to yearend. Remember…”Use It or Lose It” or have $500 or less in your account if your employer always you the roll over option.

Advantages of HSA or FSA

  1. All contributions are pretax. This means if you are in a 25% tax bracket and save $100 per month/$1,200 annually pretax, you will save $300 per year.
  2. When selecting your health insurance plan, determine the premium differences between plans and decide if funding a HSA or FSA can save you any money
  3. Remember…..you are going to pay for medical expenses regardless if you have a HSA or FSA or not. Better to pay with pretax dollars versus post tax.

How to determine the Amount to Fund my HSA or FSA

  1. Add up the following:
    1. Your Deductible amount
    2. Estimated Co Pays and expenses for:
      1. Doctor Visits
      2. Prescriptions
  • Dental Expense
  1. Eye Expense
  2. Any planned surgeries, etc…
  3. Any other Medical Expense specific to you
  • The sum of the above should provide you with a base line Medical Expense Amount.
  1. There are no dumb questions. Ask your Human Resource Department for information if you are unsure.

A Summary of HSA/FSA Common Qualified Medical Expenses may include:

Acupuncture Eye glasses/eye surgery
Alcoholism…Rehab Hearing aides
Ambulance Hospital amounts not paid
Amounts not covered under another heal plan Laboratory fees
Annual Physicals Medicines
Body Scans Optometrist
Post-mastectomy breast reconstruction surgery Orthodontia
Chiropractor Osteopath
Contact lenses Oxygen
Co Pays amounts not paid Prosthesis
Co-Insurance amounts not paid  Surgery, other than cosmetic
Crutches Therapy
Deductible amounts Transplants
Dental Exams Weight-loss program…prescribed
Eye exams Wheelchairs

The above list is basic summary of Qualified Medical Expenses.  For a more detail list of Qualified Medical Expenses, either access the Plan Administrators web site, call the Plan Administrator or your ask your Human Resource Department.

For over-the-counter medicines and supplies, the IRS does not allow HSA or FSA contributions to be used.  Talk to your doctor and ask if he or she can write you a prescription for your documentation.  Then you can use the HSA or FSA for those items.

For a specific list of qualified medical expenses, see IRS publication 502: (http://www.irs.gov/publications/p502/index.html)

A Summary of HSA/FSA Common Non-Qualified Medical Expenses may include:

Concierge services Health club dues
Dancing lessons insurance premiums
Diaper services Medicines and drugs from other countries
Elective cosmetic surgery Over-the-counter medicines
Electrolysis cosmetic surgery Nutritional supplements
Funeral expenses Teeth whiting
Future medical care
Hair transplants

 

The above list is basic summary of Non-Qualified Medical Expenses.  For a more detail list of Qualified Medical Expenses, either access the Plan Administrators web site, call the Plan Administrator or your ask your Human Resource Department.

For over-the-counter medicines and supplies, the IRS does not allow HSA or FSA contributions to be used.  Talk to your doctor and ask if he or she can write you a prescription for your documentation.  Then you can use the HSA or FSA for those items.

For a specific list of qualified medical expenses, see IRS publication 502: (http://www.irs.gov/publications/p502/index.html)

Be proactive.  Take full advantage of what options are available.

Step V: SELECTING YOUR HEALTHCARE PROVIDERS

  1. Which doctors are in your network? 

If you have health insurance and you plan to choose an in-network doctor to keep your costs down, start by finding out which primary care physicians are covered by your plan in your area.

Your insurance plan may allow you to work with a primary care doctor who is out of network, but at a higher cost.

If you don’t have health insurance and will be paying out of pocket, you may want to talk to your prospective doctor about the cost of office visits. Knowing about costs before you need care could help you plan for future visits.

Studies have shown that cost is a major barrier to healthcare access, whether you’re seeking medicalTrusted Source or mental health treatmentTrusted Source.

  1. Who do your family and friends recommend?

One way to find a primary care physician you like is to ask for recommendations from people you trust. Your family, friends, and colleagues are excellent sources of information about doctors they like.

You can also turn to allied health professionals for their recommendations. Pharmacists, optometrists, dentists, physical therapists, and others in the healthcare field may be able to give you good information about the doctors you’re considering. Or, they may be able to offer other recommendations of doctors you should look at.

  1. How easy is it to get to this doctor?

How far is the doctor’s practice from your home, school, or office? How easy will it be to find safe and inexpensive parking? If you’re planning to use public transportation, how long will the trip take?

Primary care practices are plentiful in some communities and scarce in others.

ResearchTrusted Source shows lower-income neighborhoods tend to have more “safety net” facilities like community health clinics, public clinics, and hospital emergency rooms than primary care physician offices.

In areas without well-developed public transportation systems, access to primary care physicians could be severely restricted.

  1. And speaking of access, where will procedures take place?

It’s a good idea to ask whether basic procedures like lab tests, x-rays, and minor surgeries are performed at the same facility as the doctor’s office.

Many primary care physicians can perform procedures like these in-office, but if you will have to travel from the doctor’s office to a lab or an imaging facility, you’ll need to find out if those facilities are easily accessible to you.

  1. Will the doctor be available when you need an appointment?

What are the hours the doctor’s practice is open? Are evening, weekend, or on-call services available? How long does it generally take to get in to see the doctor?

What about telemedicine — does this physician offer online advice or evaluations? Is there an online patient hub where you can make appointments, ask for prescription refills, complete forms, and communicate with the office?

StudiesTrusted Source show that patients find online services like these convenient, time-saving, and personally empowering.

  1. Is the prospective doctor an expert in treating people like you?

Family doctors, pediatriciansinternistsOB-GYNs, and geriatricians are all considered primary care providers.

If you want to work with a primary care doctor who is specially trained to deal with a particular demographic group or medical condition, you can check to see if the doctor is board-certified in that area.

Board certification is an extra step doctors can take to verify that they are experts in a particular field. The American Board of Medical Specialties maintains a searchable database of board-certified doctors called Certification Matters.

Medicare also offers a Physician Compare tool to help you find doctors who specialize in the kind of care you need.

If you are insured, your insurance company may also provide a ranking or rating system so you can easily locate doctors in your area who provide excellent care.

  1. Is the staff friendly and professional? 

You’re going to engage with the office staff regularly. Making appointments and rescheduling them, resolving billing issues, asking for refills — many of your interactions with your primary care provider will be handled by these unsung heroes of the medical profession.

When you interact with the staff, are they courteous and patient? Do they respect your privacy, your name and pronoun choices, along with your other boundaries? Do they help to facilitate contact between you and the doctors?

  1. Is this a group practice or an individual practice?

Some doctors practice by themselves and some practice as part of a group. It’s important to know whether you will be seeing your primary care physician, another doctor in the group, a nurse practitioner, or a physician assistant when you come in.

The quality of your care may not be affected, but your overall satisfaction might decrease if you see someone other than your regular provider.

  1. What is the physical environment of the practice like?

When you visit the office, take a look around. Is the waiting room clean, well kept, and relatively calm? Does the medical equipment appear to be modern and working well? Are the treatment rooms clean and private?

Having to wait a while in a doctor’s office is an almost universal human experience, so it’s important to be sure that the environment is pleasant.

A recent scientific survey found that the cleanliness and modernity of the practice had a big impact on patients’ overall satisfaction.

  1. Can this provider meet your special needs?

You are an individual. Your age, gender, life experiences, and medical conditions have all shaped the way you feel about your body, your health, and your interactions with healthcare providers.

As you think about what you need from your primary care physician, consider whether the doctor and the practice can accommodate your disabilities or any other special needs.

Do you experience anxiety or mistrust in medical settings because you have survived domestic abuse, sexual assault, sexual or physical abuse, racism, war, or trauma of another kind? Do you need a doctor who is informed about the special health challenges presented by being transgender or non-binary?

Keep these questions in mind when selecting a primary care provider and talk openly to a prospective doctor about their experience dealing with these kinds of challenges.

  1. Can you communicate easily with this doctor? 

The most obvious consideration is whether the doctor literally speaks your language. If your first language or your doctor’s first language are not the same, can you understand one another?

If English isn’t your first language, consider looking for a primary care doctor who can converse with you easily and comfortably in your preferred language.

Beyond the language itself, consider the following when you meet with a primary care doctor for the first time:

  • What is the doctor’s communication style?
  • Did they take the time to listen to your questions and answer them patiently?
  • Did you feel rushed?
  • Did the doctor dismiss your concerns or interrupt you frequently?
  • Did the doctor explain things to you in a way that you could understand?
  • Would you feel comfortable talking to them about sensitive or personal health issues?

ResearchTrusted Source shows that there is a strong correlation between the doctor’s communication style and the patient’s sense of satisfaction with their healthcare.

Preparing for your first visit

Thinking about these issues may help you prepare a list of questions and concerns to take with you to your first appointment.

If you are changing doctors, you will also want to request that your medical records be sent to your new doctor before your meeting. If that is not immediately possible, write down as much as you can recall about:

  • any medical or surgical procedures you’ve had
  • major illnesses and chronic conditions
  • medications you’re currently taking
  • your family’s health history

If you are used to thinking of doctors as authorities, it may feel awkward or uncomfortable to interview prospective doctors. It may make the process easier if you think of yourself as an equal partner working with the primary care physician to improve your overall health.

It may be difficult for you to trust medical professionals, especially if you have been mistreated or discriminated against in the past. It is okay if you have to try several primary care physicians before you find the right partner.

The bottom line

When you’re ready to find a primary care physician, ask around. People in your family, at your job, in your school, in the community, and even on social media can share their experiences with you. You can connect to a primary care physician in your area using the Healthline FindCare tool.

Consider the practicalities such as:

  • location
  • insurance coverage
  • hours and availability
  • access to telemedicine
  • languages spoken

Also find out as much as you can about the doctor’s certifications, communication style, and ability to meet your special needs.

Once you have whittled down your list of candidates, make an appointment with the prospective provider to ask and answer questions.

Step VI: YOUR HEALTH PLAN BUDGET

Budgeting for healthcare expense is a new process for the healthcare consumer to understand and complete.  This process is becoming more critical since the management of healthcare and associated costs have shifted to the consumer.  The following is a guide to assist the healthcare consumer in the budgeting process.

ANNUAL HEALTHCARE BUDGET TEMPLATE

Healthcare Expenses Computation Projected Annual Costs
Monthly Insurance Premiums 12 months/monthly premium  
Projected Annual PCP Visits Visits/Co pays per visit  
Projected Annual Specialty Visits Visits/Co pays per visit  
Projected Chronic Visits Visits/Co pay per visit  
Projected Annual Prescriptions Co pays per Prescription/Number of Rxs  
Elective Surgeries Out of Pocket  
Emergency Medical Expenses Best Estimate  

By now, you clearly have an idea on how complex healthcare planning is and how important it is to you and your family. This process should be an annual event.  The first year is the worst because of the learning curve.  Subsequent years will be easier.

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