Four Questions to Help You Choose a Health Insurance Plan

Open enrollment is time to enroll, renew or change health plans

Doctor touches little girl's hand while mom watches.

Open enrollment is time to enroll, renew or change health plans

Fall is upon us and so is the start of open enrollment season, that time of the year when you can sign up, renew or make changes to your health insurance plan. Many companies have their open enrollment periods in October and November with coverage becoming effective at the start of the new year. So, if you need to make changes to the coverage you currently have or switch to a new plan, now is the time to learn more about your options. 

Always remember, choosing the best health insurance plan for you and your family is an important decision. To help you make the best decision about your health coverage, consider the four questions below. Your answers should give you a better idea of what you need and want as you weigh your options.

1. Who will provide your insurance?

Most of us have health insurance through our own employer or our spouse’s and choose from the plans offered by that employer.

If you’re signing up for benefits for the first time, remember it’s common to spend some time reviewing each plan option. If you have insurance already, it’s also common to allow your benefits to renew automatically when open enrollment comes around. Just remember to check for any changes in your coverage or costs and remember to look for specific enrollment dates and deadlines.

While open enrollment offers only a window of time to make changes, remember you can make changes to your health plan at other times during the year if you qualify for special enrollment due to qualifying life events, such as marriage, birth of a child, moving or loss of health coverage.

If you do not have insurance through your employer, or are self-employed, you will need to purchase your own insurance. You can do this through a private insurance agent or broker, or through the state's health insurance exchange, Covered California. You may purchase or renew health coverage through Covered California from October through January each year.

Depending on your income, you may qualify for federal subsidies to help reduce the cost of your coverage when you purchase insurance through Covered California.

If you are 65 or older, you are eligible to obtain insurance through Medicare. You may enroll in a Medicare plan or change your current plan during the Medicare open enrollment period from October 15 to December 7 each year.

2. What type of plan do you need?

Most health insurance plans fall into one of three categories:

Health Maintenance Organization (HMO) plans require you to use physicians and hospitals from a specific list, known as the “network.” Your costs are lower when you use an “in-network” provider. If you choose a provider who is not in the network, your care is usually not covered. You may be responsible for the entire bill unless it is an emergency. Also, your primary care physician must refer you to specialists or other services for them to be covered by the HMO.

Exclusive Provider Organization (EPO) plans are similar to HMOs but may not require a referral from your primary care provider to see a specialist.

Preferred Provider Organization (PPO) plans also have a network of providers. If you use a doctor or hospital outside of the network, your PPO may cover some of the cost, but not as much as if you stay within the network. You do not need a referral from your primary care physician to see a specialist. In general, PPO plans offer a wider selection of doctors and hospitals than HMO plans but are more expensive. 

There may be a lot of variation among individual HMO, EPO and PPO plans, so read the plan information carefully.

3. What services do you need?

Think about the type of medical services that you need, including specialty care, as well as any prescription medications. If you want to stay with the physician you have now, call the office and ask which plans he or she will be participating in. If your medical needs have changed, or you want a new physician or hospital, now may be the time to change to a different plan. If you have questions about which plans include Scripps physicians and hospitals, call 858-264-3655 or visit our website to learn more about your health insurance options.

Make a list with two columns. In the first column, list what your coverage must include, such as specific physicians or hospitals, or brand-name prescription drug coverage.

In the second column, list services that you would like to have, but are willing to give up if necessary. For example, acupuncture may be on your wish list, but may not be an absolute necessity for you.

Consider your individual needs and make sure your plan covers them at a cost you can afford — which brings us to the next question.

4. How much are your premiums, deductible and out-of-pocket costs?

Premiums — the amount you pay every month for your health plan — are just part of your total insurance costs. As you review different plans, also consider their additional out-of-pocket costs, including:

The deductible is the amount you must pay out-of-pocket before your health insurance will begin to cover your medical bills. Some services, such as screening mammograms, are exempt from deductibles, but in most cases, you will have to pay the deductible before your full coverage kicks in. Generally, the higher your monthly premium, the lower your deductible (and vice versa).

A co-pay is a set amount you pay for each doctor visit, prescription, lab test and so on. For example, you may have a $35 co-pay every time you see the doctor, regardless of your deductible amount.

Coinsurance is the amount that you owe after your insurance plan pays its share. For example, your insurance may pay 80% of a hospital stay, and you pay 20%.

These amounts very widely according to the type of plan you choose, so be sure to read all information regarding costs closely.

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