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Seven Key Things to Know When Choosing Health Insurance During Open Enrollment

Seven Key Things to Know When Choosing Health Insurance During Open Enrollment

By Michael D. Miller, MD, Senior Policy Advisor, HealthyWomen

Created: 11/06/2019
Last Updated: 11/06/2019

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Open enrollment is the time when you can change your health insurance for the year ahead. There are some important things to know and consider as you make your choices. Since every individual has circumstances specific to themselves and their family, your health insurance choices should be what’s good for you and your family. However, because you cannot know for certain what your health care needs will be in the coming year, your goal is to make informed choices for you and your family. Being an informed consumer of health insurance means understanding enough to make good decisions and not to become overwhelmed by information while trying to make the “best” decision. To help you be better informed and make those good decisions, here are a few key points to remember and links to insurance-specific resources that can help.

Seven Key Things to Consider During Open Enrollment:

  1. Open enrollment dates vary by employer plan, states (for individual ACA marketplaces) and Medicare. While you might see ads describing start and stop dates, it is important to check the dates that apply to you.

  2. Health insurance is fundamentally about protecting yourself against unexpected high costs.

  3. You may be able to get financial assistance for your health insurance premiums and health care costs if you buy insurance through one of the State Marketplaces. Reduced premiums are available for households up to 400 percent of the Federal Poverty Level (FPL), which is about $100,000 for a family of four. And households with incomes up to 250 percent of the FPL qualify for reduced cost-sharing, which included deductible and co-payments.

  4. If you are taking an expensive medicine for a chronic condition - and you change health plans - a new plan may require you to try another medicine before they will pay for the one you are currently using. Or, the new plan may not cover the medication, or require documentation from you or your clinician’s office explaining why you need to continue the medicine you’ve been taking. In addition, the amount you could pay for your current medicine (or a new one) could be different than what you are paying in your current plan. These are two examples of things to ask about and explore when considering a new health plan for 2020. (You may also ask your clinician’s office about their experience with such “prior authorization” and access restrictions from health plans you are considering.)

  5. Similarly, if you are seeing a specialty clinician (such as a rheumatologist, neurologist or cardiologist), a new health plan might not include them as “in-network” providers, which would mean the new plan would not pay for care from their office, or you could have to pay more than your current plan. Also, some new plans may have higher co-insurance percentages for seeing your specialists – something else to be aware of when considering new health plans.

  6. Almost all insurance (except traditional Medicare) has a limit on what you are required to pay in a year for (in-network) health care services. (This is in addition to the monthly premiums.) This “out-of-pocket cap” in 2020 will be no more than $8,150 for individual coverage and $16,300 for family plans that meet ACA requirements.

  7. Be cautious about ads and phone calls for health plans that offer very low premiums. Marketing for such “skinny” plans – such as short-term/limited duration plans, Association Health Plans, and sharing ministries – seems to have increased dramatically this year, but they are not required to cover many things, (such as prescription drugs, mental health services, or maternity care), and since they do not have to comply with ACA standards for health insurance, such “skinny plans” may provide limited financial protection with a very high “out-of-pocket” cap, or a limit on how much they will pay in a given year.

Health Insurance Open Enrollment Resources