Originally posted September 6, 2013 on https://www.thestreet.com

This year’s open enrollment season for selecting workplace benefits comes just before some of the biggest changes of health care reform go into effect.

Never before has it been more important to pay attention as you choose a health plan for you and your family.

“You really need to do your homework this year,” says Carol Taylor, an employee benefit adviser with D & S Agency Inc. in Roanoke, Va.

Here are 5 tips for open enrollment this fall.

1. Understand the health care reform individual mandate: You must have coverage.

Starting in 2014, federal law will require virtually everyone to have health insurance or face a tax penalty. So if your employer doesn’t offer health insurance for next year or your company’s health plan doesn’t meet certain minimum standards, you’ll need to shop for health insurance on your own. Your employer must let you know by Oct. 1 whether its health plan meets “minimum standards,” says Taylor, a member of the National Association of Health Underwriters National Legislative Council.

To meet the minimum standards under health reform, employers must offer coverage at the “bronze level,” which is one of the four levels of coverage defined under health reform provisions. The other three are silver, gold and platinum. They are based on actuarial value, which measures the amount of financial protection the policy offers, or the percentage of health costs a plan would pay for an average person. For a bronze plan, the insurance would cover 60 percent of all health care costs for an average person. Enrollees, on average, would be responsible for paying 40 percent of the costs.

If you’re shopping for an individual health plan, you can buy one from an insurance company directly or through your state’s new health insurance marketplace. The online health insurance marketplaces, sometimes called exchanges, are scheduled to open for business Oct. 1. Coverage can begin Jan. 1.

If you’re not eligible for coverage through an employer or your employer’s plan doesn’t meet government standards, then you might qualify for a tax credit to save money on premiums when you buy a marketplace plan. People who earn up to 400 percent of the federal poverty level — that’s $94,200 for a family of four in 2013 — will be eligible for premium subsidies in the form of tax credits. People who earn up to 250 percent of the federal poverty level will be eligible for lower deductibles and copayments.

2. Don’t assume your family will qualify to save money in the new marketplaces.

Think you can get a better deal in the new marketplace than what your employer is offering? Maybe not. If you and your family have access to affordable employer-sponsored health insurance that meets minimum standards, then you and your dependents are not eligible for premium tax credits or help with cost-sharing – which includes aid in paying deductibles, copayments or co-insurance — in the new marketplaces. You can shop there, but you’ll pay full price.

“Affordable” means you pay no more than 9.5 percent of your household income toward the coverage for yourself. The amount you pay for your dependents to be covered on the employer-sponsored plan isn’t factored into the equation. So even if you have to pay a bundle to keep your dependents on the employer plan, they’re still not eligible for subsidies in the marketplace if the portion you pay to cover yourself is deemed affordable and they have access to the employer plan.

That could put a lot of moderate-income families with a sole breadwinner in a financial bind, says Mindy Anderson-Wallis, president of Employee Benefit Solutions of Indiana in Lafayette, Ind.

3. Compare benefits and health insurance plan networks.

Check out the provider networks of the plans you’re offered to make sure your doctors and preferred hospital system are included, especially if you have a serious or chronic condition and are undergoing treatment. Given all the standards that must be met, one way health plans may cut costs is to cut the provider networks, Taylor warns.

You pay substantially more out of pocket to see providers outside the network with a preferred provider organization (PPO) plan. Except in special circumstances, you typically pay for the full cost of services for providers outside the network with a health maintenance organization (HMO) plan.

4. Understand that your employer doesn’t have to offer coverage in 2014, and it won’t have to offer coverage to your spouse.

Starting in 2015, the Patient Protection and Affordable Care Act will require employers with at least 50 workers to provide affordable health insurance for workers and their dependents or pay a penalty. The so-called employer mandate was supposed to go into effect in 2014, but the Obama administration delayed implementation for a year.

Still, most employers are gearing up for the mandate, and there’s one tricky technicality you should know. The federal government will define dependents as children, not spouses. So even when the employer mandate goes into effect, your workplace won’t have to offer coverage to your spouse.

Nobody knows yet how this will play out, but Anderson-Wallis says she doesn’t think the definition of “dependent” will have much impact.

“I don’t think we’ll see large employers not continue to cover spouses,” she says. “Benefits are seen as a way to attract and retain employees.”

If your spouse isn’t eligible for employer-sponsored coverage, then he or she will qualify for a tax credit to save money on a health plan in the new marketplace if your household income is less than 400 percent of the federal poverty level.

5. Crunch the numbers and pick the health insurance plan with the best value.

Compare the out-of-pocket costs of each health plan if your employer offers a choice of plans. Your costs include:

  • Deductible.
  • Doctor visits, urgent care and emergency room copayments.
  • Co-insurance — the percentage the health plan pays after you satisfy the deductible.
  • Prescription drug copayments or co-insurance.
  • Your portion of the premium.

Consider how often you go to the doctor, the medicines you take and what services you might need in the next year. Run some scenarios to see how much each health plan would cost, and choose one that meets your unique needs.

“Don’t just roll the dice without calculating,” Anderson-Wallis says.