ACA open enrollment: What to look for -- and to avoid

Finally some good news about health insurance. Consumers shopping for coverage during the 2019 health care exchange open-enrollment period, which runs Nov. 1 to Dec. 15, may get a break in premium costs.

For the first time since the Affordable Care Act was passed, premiums will go down, according to the department of Health and Human Services. Prices on average are predicted to drop 1.5 percent percent for silver plans, the most popular mid-range option on the exchanges.

In addition, for the first time since 2015, the number of insurers participating in the exchanges will increase, according to HHS. In years past, insurers who had trouble making the exchange business profitable, and others, uncertain of the future of the health care law under President Donald Trump, pulled out of the exchange business, leaving consumers in some areas of the country with limited choices.   

Both HHS Secretary Alex Azar II and Seema Verma, administrator of the Centers for Medicare and Medicaid Services, both public critics of Obamacare, said recently the Trump administration should be credited for these improvements. President Trump tweeted the same. 

"Under President Trump, premiums are dropping and choices are returning," Azar said at a recent health conference.

Critics point out that if it hadn't been for some of the Trump administration's moves to dismantle the law -- including eliminating the individual mandate that required people to sign up for health insurance or pay a tax penalty -- exchange shoppers would be seeing much more dramatic drops in premiums this year. A Brookings Institution report released in August concluded that without the efforts to eliminate or water down Obamacare, ACA premiums would have dropped an average of 4.3 percent for 2019.

Nevertheless, any premium relief is welcome news, especially for people who don't qualify for government subsidies designed to help with premium costs. These consumers have been bearing the brunt of premium increases in the past few years.

Yet, even with a more positive open enrollment approaching, it bears repeating that consumers need to shop carefully on the exchanges. Here's some advice from experts including Cheryl Fish-Parcham and Claire McAndrew, both from the health care advocacy group Families USA.

Don't be fooled by new, non-ACA, insurance plans

In the past several months, the Trump administration has paved the way for two alternative types of insurance that won't be subject to the same standards as ACA-regulated policies. The administration loosened restrictions on both short-term health plans and so-called association health plans, both of which are usually cheaper than exchange plans. But they often provide much less coverage of essential health benefits such as maternity care or treatment for preexisting conditions.  

Marketing efforts for alternative policies have started in earnest, said Fish-Parcham. If you're searching on the web to find insurance information, these plans may pop up, and it isn't always clear that they aren't exchange-based plans, she explained. 

In addition, fraudulent telemarketing calls for health insurance are on the rise. "I've gotten at least a call a day from some health care enrollment center that sounds like it might be part of the exchanges but is not," Fish-Parcham said.

For exchange information, stick close to the healthcare.gov site for federally run exchanges or, if your state runs your exchange, the official state exchange site. "That's where you'll find comprehensive policies that meet ACA standards," Fish-Parcham advised.

Look at all "metal" levels

Be sure to compare all levels of coverage carefully, especially if you qualify for a subsidy. Gold plans, for instance, come with higher premiums but lower deductibles and other out-of-pocket costs. For some consumers with high out-of-pocket costs, premium subsidies help make these seemingly more expensive plans more affordable overall than some of the higher-deductible silver and bronze plans.

Get to know the term "pre-deductible"

If a high-deductible plan is all you can afford or otherwise makes the most sense for you, compare options carefully to find what each policy covers before your deductible is met. Under the law, annual physicals and some preventive care screening such as mammograms are covered 100 percent before the deductible. 

But some policies go further and cover some medicines or a certain number of primary care visits before you've paid the entire deductible. If you're generally healthy, you may find that a policy with a high deductible but generous pre-deductible benefits will meet your needs.

Check your provider network  

Marketplace insurers often keep costs down by negotiating lower reimbursements with a very limited network of providers. These contracts with providers change all the time, explained McAndrew, so it's important to check the list of providers included in any plan you're considering, even your current policy that you may like.

Check the provider directories of all the plans available on your exchange to see if your doctors are still included. If you can't find your providers on the policy you want, simply call your doctors to double-check if they're still part of the network.

Keep in mind that even if your policy has a very narrow network, it shouldn't be so narrow that you can't use your insurer to find the specialized care you need in a timely manner, McAndrew said. If you have to go out of network because no provider is available within it, your treatment should be covered, she added.

Look beyond 2019

The outlook for the ACA and its health care exchanges may not be so positive past 2019. Ongoing legal and Congressional actions may affect the law's future and that of the health care exchanges, particularly for people with preexisting conditions.

Last month, a federal judge heard arguments from 18 state attorneys general and two governors in a lawsuit designed to strike down the Affordable Care Act. The AGs argue that with the individual mandate fine having been eliminated as a result of the 2017 tax law, that mandate is unconstitutional and the entire law should be eliminated. 

If the courts rule in favor of the argument, all protections under the ACA, including the most popular protection for people with preexisting conditions, would no longer exist. Back in June, the Trump administration decided not to defend the ACA against this lawsuit, and it agreed in part that protections for people with preexisting conditions should be overturned.

Since then, President Trump has spoken in favor of protecting consumers with preexisting conditions, and a group of Senate Republicans has introduced a bill that would protect sick consumers, although health care advocates have poked holes in the proposed legislation.

As the ping pong game continues, Fish-Parcham warned, people signing up for insurance during this year's enrollment period need to be aware that the future may look very different.