• Health insurance – What’s the best fit?

Everyone must have health insurance by the end of March 2014, or pay a penalty.Posted Jan. 7, 2014


Record Editor


Everyone must have health insurance by the end of March 2014, or pay a penalty.

Yet reading the large print on insurance applications and programs is sometimes as confusing as deciphering the fine print.

Smart Choice, a seminar offered by the NDSU Extension to help individuals learn their way through the language and pick the insurance program that best fits their individual needs.

“There are several ways to obtain health insurance,” said Samantha Roth, Extension Agent for Stark and Billings County. “Through your employer, private insurance company, government programs like Medicare (if 65 or older) or Medicaid (based on income) or on the Marketplace.”’

Each individual’s need is different for insurance, and Roth said there are three key questions to determine before shopping for health insurance – Why do I need it? What do I need? How much can I afford?

“Insurance gives peace of mind, helps protect your assets, and gives you options as your lives progress,” she said. Whether covering a growing family or as an older couple, knowing if something happens it won’t ruin you financially helps people sleep at night.

In 2010, she said, unpaid medical bills caused 42 percent of all bankruptcies.

Without insurance, people tend to put off going to the doctor because it’s unaffordable, or they can’t get into a doctor without some kind of coverage. Many wait until they become so ill the emergency room is where they end up – at a much higher cost, and much sicker than if they had seen a health care provider at the beginning.

What coverage is needed again depends on individuals and their families.

“If you are planning on having a baby, maternity coverage is something you would need,” she said.

A prescription plan of some kind is usually something everyone needs. And they also vary. Some require a co-payment that differs for generic or name brand drugs, some require a deductible before the insurance will begin to pay. For a patient who takes regular medication, such as high blood pressure medication, a different prescription plan would be more beneficial than someone who may only need an antibiotic or other medication a time or two a year.

Other additional insurance may be purchased for vision and dental care, if needed.

“Go over your medical bills, including dental, vision and prescriptions for the last year, and then see if there are changes you are planning for the coming year, such as a new baby,” Roth advised.

Done with help and a plan the process won’t seem so overwhelming.

Essential health benefits

Under the Affordable health Care Act the following 10 categories must include at least within the following 10 categories:

• Ambulatory patient services

• Emergency services

• Hospitalization

• Maternity and newborn care

• Mental health and substance use disorder services, including behavioral health treatment

• Prescription drugs

• Rehabilitative and habilitative services and devices

• Laboratory services

• Preventative and wellness service and chronic disease management

• Pediatric services, including oral and vision care


“It is important to have as much information as possible before you go looking for insurance,” said Roth. “Learn the language, know what you need and what you can afford.”

The “packages” of bronze, silver, gold and platinum offer lower premiums and higher out-of-pocket expenses to higher premiums and lower out-of-pocket, respectively. Tax credits may also be available for those choosing a bronze package, dependent on income, but only if the insurance is purchased on the Marketplace.

Some insurance, such as some dental plans, have a limit of what they will pay during the year and over a lifetime. Health insurance has an out-of-pocket limit of what the consumer pays per year – then the insurance company picks up medical costs for the remainder of the year.


Insurance companies also pay differing amounts depending on where you receive your medical care.

“If you are in a PPO program (preferred provider) and use a doctor not in the plan, the insurance won’t pay as much,” said Roth.

There is a lot of information needed before signing on the dotted line, to get the coverage each individual can afford, and to make sure they have the coverage they need.

“The first step is to find out if you are eligible for Medicaid,” said Roth.

North Dakota is accepting applications for the Medicaid expansion program. Visit apply.dhs.nd.gov to see if you qualify, she said.

Talk to a private insurance agent or broker, who can help answer questions. Visit the Marketplace (marketplace.com) for more answers, or call the ND Department of Human services at 1-877-543-7669 in Bismarck.

To get through the federal health insurance marketplace, visits www.HealthCare.gov, or call 800-318-2596 to talk to a federally approved navigator to learn more about options.