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Health Insurance Open Enrollment: The forgotten season

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Most Americans celebrate the last three months of the year with three big holiday seasons: Halloween, Thanksgiving, and Christmas (Happy Hallothanksmas, y’all)(huge apologies to my Jewish friends). But there’s another very important season that we all need to be aware of: Health Insurance Open Enrollment. This is the annual window for you to sign up for a health plan that fits your needs for the next calendar year.

The official government season runs from November 1, 2021 to January 15, 2022 for 2022 coverage. Most employers run their work-sponsored enrollments sometime during this window, too. That’s strategic. Just because your employer offers health insurance doesn’t always mean that its the best deal for you. Don’t be afraid to shop around. Here are some tips to consider while you’re at it.

Tip #1: Check the Price Tag

When we talk about health care, the price you’re quoted isn’t the price you’re ultimately going to pay. It’s one of the most frustrating things about the American health system (you know, besides everything else). To really estimate how much you’re going to spend, it helps to take a look at what you’ve paid in the past 12 months. Things like prescriptions, doctors visits, and specialist visits all need to be factored in as well as the monthly premiums.

Many enrollment sites now include calculators to help you determine if a lower-premium-higher-out-of-pocket plan will serve you better than a higher-premium-more-coverage plan. Despite this, picking the right plan for you can be as much art as it is science. Since no one can predict the future, you have to do the best with the information you have during health insurance open enrollment.

Tip #2: Shop Around

You might have access to a couple different marketplaces and it could be worth your time to check them all out. Some options are:

  • Your workplace, or your spouse’s
  • Federal marketplace
  • Local or state marketplace
  • Private Exchange
  • A membership group or fraternal organization you are a part of
  • Directly through insurance providers

Generally, healthcare offered through your job will be the most cost effective. That’s because your employer will pay for a part of the plan as a benefit to you. Companies often pay half of the cost. It’s a deductible expense for them and can be huge savings for you.

But if you work for a smaller employer, or your options are limited, it may make more sense to go to the Affordable Care Act marketplace. This is especially true right now, since one of the COVID-19 support bills changed the rules for receiving a subsidy. Thanks to this bill, Silver plan healthcare should cost no more than 8.5% of your household income, no matter how much you make.

Tip #3: Learn your Health Plan ABCs

Healthcare is almost as bad as personal finance in their love of acronyms. Thank whiskey there are should only be four common health plan types you’ll come across: HMO, PPO, POS, EPO.

HMO = Health Maintenance Organization

An HMO has its own network of doctors and hospitals. It uses this network to enforce prices and (hopefully) keep costs down for its patients. With an HMO you have a Primary Care Physician (commonly abbreviated to PCP. Okay, there is a fifth acronym you need to know. It’s not my fault!) who determines if you need to see a specialist.

Pro: HMOs tend to have lower premiums and out-of-pocket costs

Con: You need to see providers in your network, otherwise your care might not be covered at all. You’ll also need to go through your PCP for pretty much everything, unless it’s an emergency.

PPO = Preferred Provider Organization

A PPO also has a network of providers they would prefer you use — hence the name — but a PPO is more flexible if you need to go out of network.

Pro: You get the most freedom. Your primary care physician doesn’t determine if you get to see a specialist. You have more flexibility about where you get care.

Con: That flexibility is going to cost you, both in bigger out-of-pocket bills if you do go out of network and higher monthly premiums in general.

POS = Point of Service

Like an HMO and a PPO had a baby, a POS plan is a combination of both. You’re going to have to designate a Primary Care Provider just like in an HMO, but your PCP can refer you to specialists outside of the network and you’ll still be covered.

Pro: Flexibility in providers

Con: Your PCP is coordinating your care. And venturing outside your network on your own will come with a higher price tag. (And, if you’re like me, you might accidentally translate POS to Piece of Shit, even when you don’t mean to).

EPO = Exclusive Provider Organization

Basically an HMO without the PCP. As long as you stay in network, you can go to specialists. EPOs are less common than the other three on this list.

Pro: You can get the care you need without a referral. EPOs tend to have larger networks than HMOs

Con: Unless it’s an emergency, you have to stay in network to be covered. You may need to get pre-approval for procedures, since a PCP isn’t overseeing your care.

Tip #4: Make Sure your Current Providers are Covered

After reading the types of plans offered, you can see why making sure your doctor/hospital/specialist is in your network is so important. Take the time to screen a plan’s list of providers before committing.

Yes, this all may seem like a lot of work, but taking the time to really think through your options during health insurance open enrollment can save you thousands of dollars throughout the year. Most employees spend an estimated 18 minutes on their healthcare plan decisions. Don’t be one of those. Just take a deep breath and take things slowly. You got this.

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