What to Review During Open Enrollment

Even if you’re happy with your current plan, it’s important to review your coverage. Make sure it still fits your needs — both today and for the year ahead. Costs, provider networks and benefits for health care and prescriptions can change. Your own needs may change as well. 

This is your opportunity to confirm that your plan still works for you. You can also compare other options, some of which may offer better value, greater flexibility or expanded coverage for the coming year. 

Consider what kind of care you may need in the year ahead. If you’re having a baby or have a procedure planned, you may want more coverage.

If you have a chronic condition like diabetes, you may need many doctor visits and prescription drugs. A plan with low deductibles and copayments could help you.

Make sure your preferred doctors and medical centers are in the network in the plan you are reviewing. If they are not included, you may have to pay more. 

It’s easy to compare monthly premiums — the amount you pay each month to keep your health insurance active, even if you don’t use services — but there are other expenses to consider.

Add up all potential costs, including:

Deductibles, the amount you pay out-of-pocket for covered care before your plan begins to pay; check if your deductible applies to preventive health and wellness services.  

Copays, what you must pay when you get care. 

Coinsurance, the percentage of your medical costs that you pay once you hit your deductible. 

Make sure to review all costs carefully before making your decision. A plan with a low premium may not be the cheapest choice. High deductibles and copayments can lead to higher overall costs. 

When choosing a health insurance plan, you typically select between a PPO and an HMO. Key differences between the two include cost, network size, access to specialists and coverage for services outside the network. 

HMO (Health Maintenance Organization) plans offer care within a specific health system that includes a network of doctors, hospitals and other medical services. 

An HMO plan typically has lower monthly premiums, lower out-of-pocket costs and a lower deductible if the plan includes one. You are required to select a primary care physician (PCP) to coordinate your care, including referrals to specialists. HMO plans won’t cover out-of-network care unless it’s an emergency.  

PPO (Preferred Provider Organization) plans offer broader networks of care and more flexibility. 

PPO plans are usually more expensive, with higher monthly premiums, higher out-of-pocket costs and often have a deductible that you must meet before services are covered. You can get care outside of your network, though you will likely pay more. You usually do not need a referral from your primary care physician to see a specialist.  

Most health insurance plans follow the Affordable Care Act (ACA). This includes plans provided by employers.

To see if your plan follows ACA rules, check your summary of benefits and coverage, which shows what your plan covers and its costs. Look for the 10 essential benefits that ACA requires:

• Outpatient care 
• Emergency services 
• Hospitalization (such as surgery) 
• Pregnancy, maternity and newborn care 
• Mental health and substance-use treatments 
• Prescription drugs 
• Rehabilitative services and devices 
• Laboratory services 
• Preventive and wellness services and chronic disease management 
• Pediatric services, including oral and vision care (dental and eye care coverage not mandatory for adults) 

• Acupuncture (may be covered by some employer group plans)
• Dental care (separate dental plan needed as most health plans don’t cover)
• Cosmetic surgery (may be covered for medical reasons)
• Laser vision correction surgery 
• Fertility treatments (some employer group plans may offer)

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

Most plans place medications into four tiers, which determine how much you’ll pay. They are generic, brand-name, non-preferred and specialty. Generics tend to have the lowest copay; specialty prescription 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.”  

Some plans require you to try lower-tier drugs before using name-brand drugs.  

If you miss open enrollment, you cannot change your plan until the next period. The only exception is a major life event, such as getting married, having a baby, losing a job, moving or a family member passing away.

Understanding the deadlines and confirming the dates are important as you consider your options.

• Employer-sponsored health insurance: Employer sets the dates, usually during the fall; check with your HR department for details.
• Medicare annual enrollment: Oct. 15 to Dec. 7. 
• Covered California’s open enrollment: Nov. 1 to Jan. 31. 

Scripps accepts many health insurance plans, enabling patients to receive high-quality health care that is rated among the best in the nation. Whether you have medical insurance through your employer or Covered California, choose a plan that includes Scripps.