Open Enrollment Health Plan BasicsNavigating Open Enrollment Health Plans

Open enrollment for health insurance begins November 1st! With all the recent healthcare law changes there are more options than ever before. All the choices and new procedures can be overwhelming. This article will break down the different healthcare terminology so that you can be thoroughly educated and get the best plan for the best price.

Essential Health Benefits

With the newly enacted healthcare laws, there have been changes to what all health insurance plans must offer. No matter what level of coverage you are paying for you will receive coverage for all the Essential Health Benefits. These benefits are:

  • Addiction Treatment
  • Ambulatory Patient Services
  • Care for Newborns & Children
  • Chronic Disease Treatment
  • Emergency Services
  • Hospitalization
  • Laboratory Services
  • Maternity Care
  • Mental Health Services
  • Occupational & Physical Therapy (see here)
  • Prescription Drugs
  • Preventative & Wellness Services
  • Speech-Language Therapy

It is important to not you still may have to pay a co-payment or co-insurance for some of these services. However, your healthcare insurer will still cover the majority of the cost.

Health Plan Levels

Under the new laws, all healthcare plans are categorized by 4 different levels-Bronze, Gold, Silver, & Platinum. The plan levels are based on the actuarial value of the plan. Actuarial value is the average percentage of your healthcare expenses that the plan will cover. However, the more coverage your plan provides the more expensive your premiums will be.

Here is a breakdown of the actuarial value of each plan level:

  • Bronze: These plans will cover 60% of your expenses and you will be responsible for the other 40%.
  • Silver: These plans will cover 70% of your expenses and you will be responsible for the other 30%.
  • Gold: These plans will cover 80% of your expenses and you will be responsible for the remaining 20%.
  • Platinum: These plans will cover 90% of your expenses and you will be responsible for the remaining 10%.

Understanding Out-of-Pocket-Costs

Now that you understand what Essential Health Benefits all plans must cover, as well as what the four plan levels are, it is important that you know the different out-of-pocket-costs that will be associated to whatever plan you choose.

  • Premium: This is the amount you must pay each much to the insurance provider to retain coverage. You must pay this each month regardless of if you use any plan services.
  • Deductible: This term refers to the amount you must pay out of pocket before your insurer starts to cover costs. For example, if your deductible is $3,000, you must pay 100% off all health care costs until you reach that $3,000 mark. After that, your insurance coverage will kick in.
  • Co-payment: The term co-payment refers to fixed amounts that you will pay for certain services. For example, a doctor’s office visit may cost you only a $25 co-pay and your insurer will cover the remainder of the bill. It is important to note that co-pays do not count towards your deductible.
  • Co-Insurance: If your plan includes co-insurance, this coverage will not kick in until you have reached your deductible. Once you have met your deductible your insurer will cover a fixed percentage of all healthcare costs. You will be responsible for paying the remainder. For example, if you have 80/20 co-insurance and you receive a bill for $100, your insurer will pay $80 and you will be responsible for paying the remaining $20.
  • Out-of-Pocket-Maximum: Sometimes referred to as Out-of-Pocket-Limit, this is the limit the policy sets on the amount that you must pay out of pocket for health care costs each year. Each plan will differ on what these amounts are. But after you reach your limit your plan will cover 100% of your health insurance costs.

Choosing the Right Plan for You

Now that you are educated on the basics of the new health insurance policy setup, what is your next step? You will need to weigh the costs and benefits of several plans to find one that has sufficient coverage, yet falls into your price range. If your income meets certain requirements, you may even be eligible for cost sharing or tax credits that will help to reduce the cost of your health insurance premiums.

Typically, you cannot enroll in a new plan until the annual open enrollment period, which falls between November 1st and January 31st each year. During this time, you can meet with an experienced insurance agent who can explain your plans in depth, as well as help you to apply for the best plan for you.