Patient examines open enrollment form for health coverage. (Catholic News Service)
Patient examines open enrollment form for health coverage. (Catholic News Service)

The Supreme Court will likely decide in June if citizens in states that opted out of setting up their own Affordable Care Act health insurance programs will lose their insurance.

Many experts say even if the Supreme Court rules against the Catholic Hospital Association and other supporters of the ACA, Oregon is in a different class.

“We don’t know what will happen with the Supreme Court decision,” says Shelia Jameson, account manager at Sisters of Providence Health System. “Oregon is what they’re calling a state-supported based marketplace. We should be OK.”

A state-supported based marketplace? What?

That’s as good an introduction as any to the mysterious world of health insurance, a world with impenetrable language and confusing rules. So what’s a regular human being, possessing a body vulnerable to disease and injury, to do?

“We have to become better consumers of healthcare and understand our benefits,” says Jameson.

In other words, homework.

The right healthcare really is the same for everyone: it’s treatment for what ails you when you need it.

The choices and differences come when you’re figuring out how much insurance you can afford. Usually the more insurance the more trouble free the treatments… and the bigger bite out of your wallet — unless, of course, you’re hit by something big.

Jameson compares online shopping for health insurance to shopping for any product online. You need to understand the terminology in order to compare insurance plans so you’ll know what’s right for your income.

 Understanding your insurance

If you’re like most Oregonians, you have insurance, either through your employer, through an individual plan, or through healthcare.gov. This is the time to be learning how best to use the insurance you’ve already got. Once you understand your plan, you’ll know whether you want to change it in the next open enrollment period, which begins November 1.

Jameson urges people use the preventative care that is now covered: mammograms, pap smears and (often) annual exams.

Take a look at your coverage, usually found online through your insurance provider, and learn exactly what is free and what other services cost.

If that information is confusing, call your insurance company. They’re staffed with people to explain it.

Insurance agents are trained in that as well, so don’t hesitate to call an agent.

Most insurers also are set up so that you can check your own healthcare visits online, and check too on what you’ve paid and what you owe.

Providence is setting up a new treatment cost estimator, showing what members’ out-of-pocket costs are at various facilities. “That means that if your doctor talks with you about a knee replacement, you can see what it might cost at various facilities,” says Jameson.

Those costs vary, with some hospitals charging more than three times what another might for the same surgery. National research has shown that paying more does not necessarily result in better outcomes. Oregon’s “PricePoint” estimator is at orpricepoint.org.

Fined? Enrollment open

A few Oregonians can still sign up for insurance through last year’s open enrollment period, which ended for most on February 15. If you learned as you filed your taxes that you were hit with a penalty for not having insurance, then you can still sign up through the Affordable Care Act. The extended enrollment for people in that situation ends on April 30, so act fast.

That fine, by the way, will only become more painful. It’s already a chunk of cash: $95 per adult and $47.50 per child under age 18, up to a $285 per family, or else 1 percent of your income (above a low base threshold) whichever is greater. That fine is slated to rise to $325 per adult or 2 percent of income in 2015.

There are in addition always circumstances that make insurance changes possible: having a baby, getting married, losing a job, getting and job and so on.

Get the app

Of course they invented an app. CNN reported recently that a top new financial app for your computer or phone is Simplee, a free service through the web, for Androids, and for iOS (iphones).

You plug in your insurance plan and the program will show you how much you’re going to pay out of pocket, either through your deductible, copay, or coinsurance. A sister app, Simplee Pay, can set up a payment plan.

Speaking the health insurance lingo

Talking with your doctor takes preparation and making sure you understand how to describe your symptoms, and sometimes taking notes so you can revisit what your doctor told you and learn more.

Talking with a health insurance agent or your health insurance provider also takes preparation if you’re going to be a good manager of your own health care.

There’s no better way than the words involved to show just how different health insurance is from healthcare itself.

Gone are terms like blood pressure, virus vs. bacterial infection, or sprains vs. broken bones. For most people, those medical terms are simple compared to health insurance terms: copay vs. deductible; PPO, HMO, EPO, health savings accounts and coinsurance.

It’s especially important to understand the difference between different types of coverage before you buy a plan.

Some of the terms that hit your pocketbook most directly are these:

Deductible: This is the amount you pay before your insurance pays anything.

Coinsurance: This is the amount you must pay for services after you have paid your deductible. Your policy probably has a ceiling or limit to how much you’ll pay during a benefit period.

Copay: This is a set amount you may have to pay each time you visit a provider, sometimes in addition to the coinsurance you’re paying.

Doing your homework

The internet has enough resources to keep you reading about health insurance for several lifetimes. Here are some places to begin:

Catholic Health Association of the United States: chausa.org

A health insurance glossary: healthcare.gov/glossary/

Blue Cross Blue Shield’s frequently asked questions: bcbsm.com/index/health-insurance-help/faqs

Learning more about healthcare policy at Commonwealth and Kaiser Family Foundation: commonwealthfund.org and kff.org

Providence Health Plans: healthplans.providence.org

Cover Oregon: coveroregon.com