It’s Open Enrollment Season – Which Healthcare Plan Is Right For Me?

It’s health­care open enroll­ment sea­son! As you pre­pare to select the right health insur­ance plan for you, there are a few things you should know before mak­ing that big decision. 

Once you’re enrolled in a health plan, you’re com­mit­ted to it for all of 2023, unless there’s a spe­cial qual­i­fy­ing event like a birth, adop­tion, or marriage. 

Learn every­thing you need to know about when and where to enroll and under­stand the dif­fer­ences between health insur­ance plans and health expense accounts. 

When Can You Enroll in a Health Insur­ance Plan? 

Depend­ing on how you obtain your health­care cov­er­age – whether it’s through your employ­er, your partner’s employ­er, an agent, or the mar­ket­place – to enroll for health insur­ance dur­ing Annu­al Open Enroll­ment you need to:

1. Con­nect with your/​your sig­nif­i­cant other’s employ­er, an agent, or health­care marketplace
2. Select a 2023 health plan 
3. Com­plete your enroll­ment application
4. Sub­mit your enroll­ment appli­ca­tion by the giv­en deadline

If you miss the dead­line, there are qual­i­fy­ing life events, such as hav­ing a baby or get­ting mar­ried, that will qual­i­fy you to enroll. 

Here are some oth­er events that will allow you to enroll after the annu­al enroll­ment deadline:

• You lose your health insur­ance due to a divorce or legal separation
• You will be get­ting mar­ried after the deadline
• You turn 26
• You lose your health insur­ance cov­ered through your job
• You give birth or adopt a child
• You become a US citizen
• You move to anoth­er ZIP code, state, or country 
• The hold­er of your cur­rent health plan dies and now you have no coverage

You can learn more about oth­er qual­i­fy­ing life events that will allow you to enroll in a health plan after open enroll­ment ends at Health​care​.gov. Note that qual­i­fy­ing life events may dif­fer for employ­er plans.

Which health­care plan is right for me?

Under­stand­ing Your Health­care Cov­er­age Options 

Some plans let you use any provider or health­care facil­i­ty, while oth­ers restrict who you can see or make you pay more if the provider isn’t a part of their net­work. There are pros and cons to each type of plan. It’s all about select­ing the one that best meets your needs. Please note that health­care plans cov­er pri­ma­ry and spe­cial­ty med­ical care needs. Pre­scrip­tion, den­tal and vision care is usu­al­ly cov­ered under sep­a­rate, indi­vid­ual plans. 

HMO (Health Main­te­nance Organization)

This type of plan usu­al­ly lim­its cov­er­age to providers that are con­tract­ed with the HMO or are with­in the plan’s net­work. The plan usu­al­ly does not cov­er out-of-net­­work care except in the event of an emer­gency. These plans also require a refer­ral from your pri­ma­ry care physi­cian before see­ing a specialist.

PPO (Pre­ferred Provider Organization)

This type of plan may also encour­age use of in-net­­work providers and may have a small­er deductible, copay or coin­sur­ance if providers in the plan’s net­work are uti­lized. Doc­tors, hos­pi­tals, and providers out­side of the net­work can be seen with­out a refer­ral for an addi­tion­al cost. This type of plan typ­i­cal­ly has the high­est month­ly pre­mi­um but often has a low­er annu­al deductible, low­er copay­ments and the most flex­i­bil­i­ty in choos­ing providers.

HDHP (High Deductible Health Plan)

This plan usu­al­ly has the low­est month­ly pre­mi­um, but the trade­off is a high­er deductible than a tra­di­tion­al HMO or PPO plan. With a high­er deductible, you pay more out-of-pock­­et ini­tial­ly before the insur­ance com­pa­ny will begin to cov­er costs. A high deductible health plan for 2023 is clas­si­fied as a plan with a deductible of at least $1,500 for an indi­vid­ual or $3,000 for a fam­i­ly. An HDH­P’s total year­ly out-of-pock­­et expens­es (includ­ing deductibles, copay­ments, and coin­sur­ance) can’t be more than $7,500 for an indi­vid­ual or $15,000 for a fam­i­ly. (This lim­it does­n’t apply to out-of-net­­work services.)

Under­stand­ing What Health Expense Accounts Might Be Avail­able to You

Some peo­ple pre­fer to use a spe­cial account to cov­er their health expens­es. If you pre­fer to have those funds sep­a­rate, you can choose a med­ical expense account. That mon­ey will cov­er qual­i­fied health expens­es such as copay­ments, deductibles, and pre­scrip­tions. Depend­ing on the type of account, there will be dif­fer­ent stip­u­la­tions about what you can and can’t buy.

Here are 2 com­mon health expense accounts:

Flex­i­ble Spend­ing Account (FSA)

An FSA is a health expens­es sav­ings account set up through your employ­er to use towards out- of pock­et med­ical expens­es. A pre-set amount is deduct­ed from each pay­check and saved in the account. Eli­gi­ble health care expens­es often include a co-pay, deductible pay­ments and cer­tain pre­scrip­tions and med­ical equipment.

Mon­ey in an FSA can­not be rolled over to be used the next year, so it is impor­tant only to save what you think you will actu­al­ly need and use each year to avoid los­ing any un-used funds. Your employ­er will also set a lim­it on the amount each indi­vid­ual can put into an FSA each year.

Health Sav­ings Account (HSA)

This type of sav­ings account also allows you save mon­ey to use towards approved health expens­es. Unlike an FSA, an HSA can only be used in con­junc­tion with a HDHP (all oth­er plans can uti­lize an FSA). HSAs are used by HDHP par­tic­i­pants pay to for health expens­es while work­ing towards the annu­al deductible to help cov­er health costs as they occur, rang­ing from office vis­its, pre­scrip­tions, over-the-counter med­i­cines, lab work and oth­er types of diag­nos­tic test­ing. Using these pre-taxed funds helps to reduce the over­all cost of the plan for the patient. Unlike FSAs, unused HSA funds can be rolled over year over year and can even earn interest. 

Now What?

Pick­ing Your Plan

Start by think­ing about what med­ical ser­vices you will like­ly use in the upcom­ing year. You can try to esti­mate based on pre­vi­ous health needs or pat­terns. For exam­ple, if you have a chron­ic con­di­tion that requires you to vis­it a spe­cial­ist every three months, you can safe­ly esti­mate four spe­cial­ty care vis­its. You may also want to fac­tor in 1 – 2 sick vis­its per year if you are prone to colds or oth­er sea­son­al ill­ness. While it is next to impos­si­ble to pre­dict exact­ly what health care you will need, esti­mat­ing your needs is help­ful to deter­mine what each plan’s actu­al cost may be.

In gen­er­al, plans with high­er pre­mi­ums pay more up-front costs. Plans with low­er pre­mi­ums (most often a HDHP) will ini­tial­ly cov­er less of your health care costs. If you don’t antic­i­pate reg­u­lar trips to the doc­tor and are not on rou­tine med­ica­tions, a low­er pre­mi­um plan may work for you. These plans will save you mon­ey each month with a low­er pre­mi­um, as long as you are pre­pared to have a high­er annu­al deductible, which you will have to meet before insur­ance starts to cov­er costs when you do need care.

If you tend to be a fre­quent vis­i­tor at your physi­cian’s office or need reg­u­lar pre­scrip­tions, you may want to opt for the high­er pre­mi­um plans (PPO or HMO plans). These plans cost more per month but will cov­er more of your health care expens­es when you receive care.

Under­stand­ing the dif­fer­ent plans avail­able is an impor­tant step towards man­ag­ing the impact health care has on your wal­let. Select­ing a plan that best fits your needs by esti­mat­ing the total antic­i­pat­ed cost of care and uti­liz­ing med­ical sav­ings accounts to help pay for out-of- pock­et med­ical expens­es can help reduce the like­li­hood of being caught off guard by a large claim.

As always, it is impor­tant to remem­ber, the plan you chose does NOT impact the qual­i­ty of care you will receive at Duly Health and Care If you have addi­tion­al ques­tions spe­cif­ic to your pol­i­cy, please con­tact your employer’s ben­e­fits depart­ment or your insur­ance carrier.

Once you enroll and your plan is active, sched­ule an appoint­ment with one of our Duly Health and Care providers. We accept more than a dozen insur­ance providers, includ­ing Medicare.