(Free!) Experts Can Help You Find the Best Health Insurance for You

The Squeeze

• There are two kinds of consultants who can help you find the best health insurance for you and your family: health care navigators and healthcare consultants
• Healthcare navigators provide their services for free, as they are funded by the federal government and work in local community health organizations
• Healthcare advocates charge a fee but can help you find the best care at the lowest charge, as well as manage your care when your family is dealing with a medical crisis (like high-risk pregnancy or a cancer diagnosis) providing research, advice, admin skills, and support.

As the year begins to draw to a close, it’s time for that much-anticipated annual event. No, not planning for the holidays; planning for your health insurance. The national health insurance exchange opened on November 1 and will remain open until January 15, 2022 (sooner if you want coverage to start January 1) — so now is the time to take a look at your family coverage and see if you can get better insurance or less expensive insurance for your needs. Or why not both? Dream big.

The only obstacle? Knowledge. Many of us spend valuable hours scrolling through websites or listening to jazzy music while on hold, trying to get the answers we need about what insurance will work for our particular situation. There has to be a better way! And there is.

Get some professional help, from people who are truly in the know about healthcare products, the inner workings of the healthcare exchange, and the offerings available in your state. And some of these professionals are available to you for — wait for it — FREE! Yes, for free. Healthcare navigators and advocates are the trained professionals who stand ready to help you manage this aspect of your life. Here, Firstly takes a closer look.

What Is a Healthcare Navigator?

One type of specialist, called a healthcare navigator, advises individuals on selecting the right insurance plan. The need for this kind of work soared over the past decade, after the launch of the Affordable Care Act (ACA) in 2010.  

Why this kind of support is needed: The ACA expanded healthcare coverage to many individuals who previously would not have been able to secure health insurance; in 2013, the health exchanges, or health-insurance marketplaces, opened up, making it easier for people to locate these lower-cost insurance programs (which are subsidized at certain income levels). 

“Most people are used to having their insurance provided through their employer,” says Susan Wilson, ACA Project Coordinator at the Council on Aging in Buncombe County, an agency in Asheville, NC. “The employer pays a portion of the insurance and the employee pays a portion of the insurance. There are very few options that the employee gets to choose from.” 

The exchange changes that, offering more choice, but when dipping into that exchange (www.healthcare.gov), things can get very complex. “Where I am in North Carolina, you can have up to 38 choices of different insurance policies,” says Wilson. “Not everyone understands the difference between an HMO [Health Maintenance Organization], PPO [Preferred Provider Organization] or other variations. It's confusing trying to figure out why one policy looks similar to another but costs so much more,” she explains.

The details can leave even the most ferocious researcher confused. “For example, what’s the difference between a deductible, co-insurance, co-pay, in-network vs. out-of-network doctors and facilities, preferred vs. participating providers? What is the trade-off between a low premium/high deductible policy vs. high premium/low deductible? Will I need a referral to see a specialist? When will pre-authorizations be required?” asks Elisabeth Schuler,CSA (Certified Senior Advisor®), BCPA (Board Certified Patient Advocate), and past president of the National Association of Healthcare Advocacy (NAHAC).

What a healthcare navigator does: A healthcare navigator can help decode the exchange options for you and determine which plan is best (think: reviewing family members who need coverage, pre-existing conditions, your budget, and other considerations). A navigator is specially trained to understand the options and help match individuals with the right plan.

What’s more, a navigator can guide you as you fill out the forms. For some people, a single blank field on the website can trigger hours of head-scratching. For example, the question about which members of the household will earn how much in a given month can be troublesome. For those who work seasonal jobs or are nearing retirement, calculating this income can be a real “but wait a minute” moment. Navigators can also address exactly these kinds of questions.

How to find a healthcare navigator: Many healthcare navigators are government-funded and offer their services free of charge. Now is the right time to contemplate working with one, since open enrollment kicked off on November 1 and ends December 15 for those wanting coverage to start on January 1^st, 2022. “We have a navigator grant that pays for our program, so we don't charge for our services and cannot accept payment or gifts. Because we don't charge for our services, we are unbiased and are more than willing to take time to explain insurance terms, provide help in understanding the differences in the various policies, work with someone over multiple sessions, and generally just provide the best service we can whether they actually sign up with us or not,” says Wilson. 

How to find one of these trained navigators? Go to healthcare.gov and click on the “Find Local Help” tab to get contact information for trained assisters and local insurance agents and brokers. You can also call the marketplace hotline (800-318-2596), which is available seven days a week, 24 hours a day. 

You may also choose to work with a privately paid advisor, especially if you can’t find a navigator in your area (funding for the free ones has been reduced in certain states in recent years). Read on to learn about those kinds of advocates.

What is a Healthcare Advocate?

There’s a different kind of healthcare specialist – usually called an advocate, but sometimes called a case or care manager, or a coordinator – who can help you when you hit those medical speedbumps that so many of us face. 

Why this kind of support is needed: For one person, that might mean facing the aftermath of a bad accident; for another, it’s learning a pregnancy is high-risk; and for yet others, it’s hearing, “I’m sorry, it’s cancer” when a biopsy report comes back. 

These situations trigger a cascade of medical care and concerns: testing, referrals, pre-approvals, treatment plans, monitoring, lots of appointments – and lots of bills. And on a more human level, they involve an intense amount of anxiety and fear for the patient and family.

“Typically, we think we have our act together and take care of whatever is needed. But with a scary or terminal diagnosis or huge medical bill – scenarios so far beyond what was expected – we are in a state of trauma and cognitive abilities fly out the window,” says Trisha Torrey, a patient advocate, founder and executive director of AdvoConnection and The Alliance of Professional Health Advocates. 

What a healthcare advocate does:  A trained, certified advocate (see resources below to find one) is an independent champion who works to get you the best care as affordably as possible and to support you and lessen the stress during your medical journey. Unlike care managers who work for a medical center – whose decisions may benefit the facility but perhaps not be in the patient’s best interest – an advocate’s sole allegiance is to their client.

There are two sides to the work these professionals do: the care side and cost side, says Torrey. On the care side, they will manage “anything required to get diagnosed and get the care that’s needed,” she says. That can be finding the right doctor for a second or third opinion or managing scheduling of complex treatment plans and accompanying you to appointments. “Then, anything with health insurance on the front end [pre-approvals and the like] and bills on the back end are managed,” she adds. This can be a huge boon given the complexity of deductibles and billing codes. They can also advise on the choice of insurance and secondary policies as well.

Consider this example from Nicole Broadhurst, a board-certified patient advocate, founder of Tennessee Health Advocates, and a member of the Alliance of Professional Health Advocates. “I recently helped a mother manage her son's medical bills following a stroke. Her son is only in his 30s and was uninsured at the time,” she says. “I was able to work with the hospital and mom to ensure he not only applied for hospital charity care but also for Medicaid in his state for these emergency services.  His bills were over $100K, when we started, and we were able to get all of those resolved to zero.”

How to find a healthcare advocate: Word of mouth is a good way to find an advocate, but also look in the directories and associations below, recommended by the experts Firstly interviewed. Do make sure you find a good fit. Says Schuler, “Working with a patient advocate is an intensely personal relationship. You must feel that you can trust and work with that person comfortably. You may need to speak with several candidates before you hire one.” The initials BCPA (Board Certified Patient Advocate) will appear after most candidate’s names, indicating they’ve passed their certification exam. 

• AdvoConnection  
• Alliance of Professional Health Advocates  
• Health AdvocateX  
• Greater National Advocates (GNA)  
• National Association of Healthcare Advocacy (NAHAC)  
• Patient Advocate Certification Board (to check certifications)  

Remember, these are privately paid services, akin to hiring an attorney; insurance will not cover these fees, but the advocate may well reduce your costs. In terms of process and costs, Schuler says, “You should also expect a written contract or agreement which specifies what the advocate will deliver to you and when, as well as a detailed explanation of fees and charges. Do not rely on verbal promises or commitments. Fees can range from $50 to $300 per hour, depending on the advocate's experience, education, niche, and location.” 

Yes, it’s an investment, but in times of crisis or with the specter of potentially ginormous medical bills coming your way, it may be exactly the kind of support you need to get you and your family through a complicated time.