How to Compare Health Plans During Open Enrollment

Even if you’re happy with your current plan, review your coverage before renewing. Premiums, deductibles, provider networks, prescription coverage and other benefits can change from year to year. Your healthcare needs may change as well. 

Compare your current coverage with other options to see which plan offers the best combination of benefits, providers and costs. 

Use this checklist to compare your current coverage with other plans available to you:

Consider the healthcare you and your family may need in the coming year, including whether you expect: 

• A planned procedure or surgery 
• Pregnancy or maternity care 
• Ongoing treatment for a chronic condition 
• Regular doctor or specialist visits 
• Prescription medications 
• Mental health care or other recurring services 

If you expect to use healthcare often, compare how each plan covers those services. A plan with a lower deductible or copayments may save you money if you use healthcare often, but it may have a higher monthly premium. 

If you want to keep seeing specific doctors or receive care at a particular hospital or health system, check whether they participate in each plan you’re considering. 

Out-of-network care may cost considerably more or may not be covered except in certain circumstances. Because networks can change, confirm coverage before enrolling. 

A low monthly premium doesn’t necessarily mean a plan will cost you less overall. Consider what you may pay when you need care. 

Premium: The amount you pay regularly to keep your health insurance coverage. 

Deductible: The amount you generally pay for covered services before your plan begins paying its share. 

Copayment: A fixed amount you pay for a covered service, such as a doctor visit or prescription. 

Coinsurance: The percentage of the cost of a covered service that you pay, often after meeting your deductible. 

Out-of-pocket maximum: The most you may have to pay during the plan year for covered in-network services under your plan.  

A plan with a higher premium but lower out-of-pocket costs may be a better value if you expect frequent medical care. 

The type of health plan you choose affects which doctors and hospitals you can use, whether you need referrals to see a specialist and how much you may pay for care. 

An HMO (health maintenance organization) generally requires you to receive care within a specific network. HMO plans may have lower premiums and out-of-pocket costs than PPO plans. You typically select a primary care physician to coordinate your care and may need a referral to see a specialist. Out-of-network care generally is not covered except in emergencies or other situations allowed by the plan. 

A PPO (preferred provider organization) generally offers more flexibility. You can usually see specialists without a referral and may receive care outside the network, though you’ll typically pay more.  

Other plan types, such as exclusive provider organization (EPO) plans, may also be available.

Compare provider networks, referral requirements and costs before deciding which type best fits your needs. 

Before enrolling, review the plan’s Summary of Benefits and Coverage to compare benefits and costs. 

Marketplace plans, including those offered through Covered California, must cover 10 categories of essential health benefits under the Affordable Care Act.  

• Outpatient care 
• Emergency services 
• Hospital care 
• Pregnancy, maternity and newborn care 
• Mental health and substance use disorder services 
• Prescription drugs 
• Rehabilitation services and devices 
• Laboratory services 
• Preventive and wellness care and chronic disease management 
• Pediatric care, including dental and vision services 

Plans may cover additional services. If you need adult dental or vision care, acupuncture, fertility treatment or other services, check whether they are covered and whether any limits apply. 

Coverage requirements can differ for employer-sponsored and other plans, so check your plan documents for details. 

Prescription coverage can change from year to year, even within the same plan. Review your insurer’s formulary, or list of covered drugs, to make sure your medications are included and affordable. 

Many plans place medications into tiers that determine how much you pay. These may include generic, brand-name, non-preferred and specialty drugs. Generic medications often have the lowest copays, while specialty drugs usually cost more. 

“The prescription copay is typically a fixed amount you pay for every drug in a particular tier; costs often do not vary at in-network pharmacies,” Dr. Keswani says. “However, if you have coinsurance, a deductible or go to an out-of-network pharmacy, your copay could change.” 

Make sure to check whether prior authorization is required and whether there are restrictions on where prescriptions can be filled. 

Open enrollment dates depend on how you receive your health insurance. 

Employer-sponsored health insurance: Your employer sets the dates, often during the fall. Check with your human resources department. 

Medicare Open Enrollment runs from Oct. 15 through Dec. 7. 

Covered California open enrollment runs from Nov. 1 through Jan. 31. 

If you miss your enrollment period, you may have to wait until the next open enrollment period. Depending on your coverage, certain life events may qualify for a special enrollment period, such as: 

• Getting married 
• Having a baby or adopting a child 
• Losing employer-sponsored or other eligible health coverage 
• Moving to an area where different health plans are available 

If receiving care at Scripps is important to you, make sure the doctors and facilities you want to use are in the plan's network. 

Scripps accepts many health insurance plans, including employer-sponsored plans and plans available through Covered California. Because participation can vary by plan, physician and facility, confirm that your preferred Scripps providers are in network before enrolling. 

Review health insurance plans accepted at Scripps as you compare your options.