A Comprehensive Guide for Arizona Families
By Karen Sanchez, Director of Family Finance, Phoenix Children’s
Originally published in October 2023
As Open Enrollment season draws near, families across Arizona will soon be tasked with evaluating their health insurance coverage and selecting a plan for the year ahead. It is no walk in the park for anyone. If you participate in an employer-provided health plan, you are probably looking at several options and potentially noticing an increase in your share of the costs. You may also be searching healthcare.gov or reviewing AHCCCS plans in hopes of making the right choice for your family.
Adding another wrinkle to this process, each insurance company offers many different plans and products – and they vary dramatically in price and coverage. Moreover, health insurance costs continue to rise overall, eating up a larger share of the family budget each year. It all makes for an overwhelming, confusing and complicated process – and yet it is one of the most important choices you’ll make for your family all year.
The Merrill Family’s Story
Christina and John Merrill are dedicated parents to 2-year-old David. Like any loving parents, they only want the best for their little boy, but life took a hard turn last year when David needed medical care for a pulmonary condition and their doctor was out of network. They never meant to pick a plan that restricted their options – they simply did not know the right questions to ask to ensure the right coverage for their young family.
While the Merrill family is fictional, there are real families across the state who have found themselves in the exact same situation. They realized – too late – their plan did not provide the coverage their children needed. Instead of focusing solely on getting their children the care they needed, they had to make impossible choices that factored in cost alongside quality of care and provider expertise.
To help you navigate this process with confidence – and avoid such a situation for your own family – we have outlined the top eight considerations for choosing your health insurance plan for 2024 and beyond.
- Ensure your providers are in-network.
Your pediatrician, primary care physician and specialists play a vital role in your family’s health and well-being. To avoid unexpected costs and disruptions in care, it is critical to ensure these doctors are listed as in-network in your plan. Do not take for granted they will be in-network, as insurance plans change every year. Contact your providers to verify they accept the insurance plan you are considering – before you sign on the dotted line.
Consider our fictional, yet all-too-real, Merrill family. David’s lung condition required highly specialized care from a team of pediatric doctors. Unfortunately, these doctors were out of network, which meant Christina and John’s out-of-pocket costs were much higher than they anticipated.
Sadly, this is not an unusual occurrence. Many families learn the hard way their doctors and specialists are not in their insurance plan’s network. This is true for kids with chronic or complex conditions like leukemia or sickle cell disease, but it is also true for otherwise healthy children who suffer a serious injury or illness requiring an emergency room visit or hospital stay.
- Check prescription medication coverage.
The cost of medications has also increased. If they are not covered by your insurance plan, the out-of-pocket expenses can be excessive. For adults and children who require specific medications to manage a health condition, it is imperative your chosen plan covers these medications.
- Understand your out-of-network benefits – if any.
“Out-of-network coverage” refers to insurance coverage for services you receive from a clinician who’s not part of your insurance plan’s approved network. While your insurance may still pay some of these costs, you will likely be stuck with a much bigger share of the bill. Out-of-network costs can include higher deductibles and co-pays or a larger percentage of the total bill. It is essential to understand the extent of out-of-network coverage your plan provides, as it can vary.
Moreover, not all plans offer out-of-network coverage. In fact, if the plan you are considering has limited or no out-of-network coverage, you could be responsible for the full cost of any out-of-network service.
Regardless, your best bet is simply to choose a plan that includes your trusted provider, clinic and health system in-network. Not only will this protect you from paying high out-of-network costs, but you will also be getting better coverage for your family.
- Beware of closed or narrow networks.
Some health insurance plans offer lower premiums in exchange for extremely limited plans with closed or narrow provider networks. These plans usually provide no out-of-network coverage, meaning you could be responsible for 100% of the bill if you seek care from a doctor or hospital that’s not part of the approved group.
While these networks may be suitable for some people, they can lead to exorbitant out-of-pocket costs for those who require specialist care or seek treatment outside the network. As kids are growing and changing, their medical needs can also change, making these plans especially risky for some families.
- Exercise caution with Health Insurance Marketplace plans.
Health Insurance Marketplace plans come with many restrictions. Even if the price seems right, double check to make sure the providers you see today – and any providers or services you anticipate needing in the future – are in-network.
- Do the math.
Low premiums might be appealing, but healthcare costs go well beyond the monthly payment. Factor in your share of costs for doctor visits, medications, hospital stays and any annual limits on out-of-pocket expenses. For families needing specialist care or ongoing medical treatment, a plan with a higher monthly premium that covers a greater share of healthcare costs through a lower deductible, co-insurance or co-payment may be a better, more cost-effective option in the long run.
- Consider the “extras.”
Some plans offer additional benefits, such as Health Savings Accounts (HSAs) or Flexible Savings Accounts (FSAs), which allow you to use pre-tax funds for healthcare expenses. Also consider other perks such as Care Coordination Services and Healthy Lifestyle benefits, which may be significant factors in your decision-making process.
- Ask questions and get answers.
Do not hesitate to contact your broker or human resources manager if you have questions about your plan. Ensure you understand exactly what your plan includes – as well as what it excludes. Understand the finer details, such as costs beyond the monthly premium.
The Merrill family’s story serves as a reminder that it is crucial to do your homework before you pick a plan. Your family’s health is on the line, so take the time you need to make an informed choice that ensures quality care, access to trusted physicians and financial peace of mind throughout the year.
Karen Sanchez is Director of Family Finance at Phoenix Children’s, where she helps patient families understand their insurance benefits, makes special payment arrangements when needed, and ensures children can access the care they need. She also oversees a team of financial counselors who work to connect children with necessary medical services, regardless of their ability to pay. Sanchez has served Phoenix Children’s families for more than 13 years. She holds a bachelor’s degree in business administration and management and a master’s in healthcare administration.