Gina Pfederhirt
Gina Pfederhirt of UPMC Health Plan

With the deadline for open enrollment looming, we turned to Gina Pferdehirt, director of public relations and community relations at UMPC Health Plan, for help in figuring out healthcare options—now.

When does open enrollment end and what are our options after that?

Open enrollment began on Nov. 1, 2015, and ends Jan. 31, 2016. If you miss the open enrollment window, the only way you can enroll later is through what is called a “qualifying event,” such as marriage, divorce, birth, moving to a new state, etc.

Health insurance has become so complicated. How do you go about getting up to speed?

The health insurance landscape has changed for many people. If you’re in your 20s and no longer covered by your parents’ plans, or if you work for a small company that has opted to not carry insurance, purchasing health insurance is a new experience. That means informed research is a must. This can include visiting insurance company websites as well as healthcare.gov, meeting with insurance agents, or talking with insurance navigators. Before you begin the process, it’s helpful to think about how you and your family use care. For instance, you should think about how often you see the doctor in a year, what prescriptions you need, and what kinds of things you think might happen in the coming year such as births, surgery, etc.

Are there elements of coverage that should be priorities for purchasers of health insurance?

The one feature of interest to many people is in-network access. That is, what are the hospitals and doctors and facilities where you want to use your coverage? If it is important to you to use a certain hospital, then it makes sense to check to see if that hospital is part of your coverage plan’s network. A second concern would be cost, and that means more than just the cost of your monthly premium. It’s also the cost of co-payments for physician visits, how high your deductible is, and how much is the total out-of-pocket maximum you would need to pay in a given year. Also, you need to know the “metallic” level of the plan you are purchasing—bronze, silver, gold, or platinum. These correspond to the average share of health care expenses that a specific plan will cover.

How do Pittsburgh health insurers interact with consumers now?

Basically, health insurers in Pittsburgh and around the country are focusing more than ever on being more consumer-oriented. In the past, the employer was the main point of contact and it was the employer, or an insurance agent, who worked on behalf of the employer, who interacted with insurers and who made the tough decisions about what kinds of insurance would be available for his or her employees.

Choosing a health plan is a new consumer experience that includes shopping for plans at a retail location such as a mall, seeking out an insurance agent or navigator, and comparison shopping online. The Affordable Care Act is changing the landscape of health insurance and it falls on more individuals to learn more about what’s best for them and their families. Once coverage is obtained, insurers may engage consumers with an online website specific to that consumer’s needs.

On the website, consumers can chat with a Member Services representative to answer a healthcare question immediately. In addition, telemedicine is an industry trend that health plans are offering and that consumers are embracing. Telemedicine enables members to communicate with a primary care physician about symptoms for common ailments and having a prescription sent to their local pharmacy on the same day, all without missing time from work and family. It’s about empowering consumers to get the information and service they need when they need it.

Why not just forego purchasing health insurance? Would the penalty be that high?

Year after year, the penalty for not getting coverage is going up. In 2015, if you did not have coverage, you had to pay the higher of two amounts: 2 percent of your yearly household income, or a $325 per person fine, ($162.50 per child under 18) with a family maximum of $975. In 2016, the penalty goes up to 2.5 percent of yearly household income, or $695 per person ($347.50 per child), with a family maximum of $2,085.

We appreciate your help on this topic but know there’s more to your life than being an expert on this topic. What’s your favorite way of spending a night on the town? 

My favorite night out always includes my husband, David, food, friends and live music.

If you could be doing anything else for a career, what would it be?

My current job is very meaningful to me; however, I love, love, love to garden, cook and design. When I grow up I want to work in gardening but hopefully with a food and fashion twist that meaningfully gives back to the community. I’m working on what that might be.

NEXT staff

The staff at NEXTpittsburgh writes about the people driving change in the region and the innovative and cool things happening here.