It’s fall again, and that means it’s open enrollment time. Employers can help employees with the challenges of selecting a health plan by giving them a how-to guide with questions and answers.

The basics
This is the season when many employers give employees a chance to pick a health insurance plan for the coming year, or reconsider the plan you already have. It’s also the time when the federal and state health insurance exchanges allow employees to select a private plan, an option that can be especially attractive if your employer doesn’t offer health coverage.

The open enrollment season doesn’t last long — the window might be open for only a few weeks — and open enrollment in the marketplaces began this past Nov. 1 and ends Jan. 31, 2017. (The deadline for the marketplaces is even tighter if you want your coverage to begin on the first day of 2017. For that, you need to enroll in or change plans by Dec. 15.) Whether you already have health insurance and are looking for a change, or you don’t have health insurance and want to understand the benefits of getting it, make the most of this time by weighing your options carefully.

Levels of coverage
When thinking about what kind of health plan to get, first consider how you use healthcare. If you’re a healthy young adult without a family, you may hardly ever step into a doctor’s office. You may even wonder why you need health insurance. One reason is to avoid the tax penalty that most people without health insurance face; another is because you never know when some kind of medical incident will occur, potentially imposing significant financial hardship on you. Still, your situation is different from a person who has children who need frequent pediatric visits, or from someone with one or more chronic diseases that require regular treatment. The healthy young adult may want to pay as little as possible for health insurance while still being covered against a serious illness or catastrophe. People who use healthcare frequently may be willing to pay more as long as their insurance covers the care they need.

That distinction is reflected in the available levels of coverage. The marketplaces classify plans into four “metal” categories. They differ based on how much you pay for healthcare compared to how much your insurer pays (based on estimated averages for a typical population). For example, if you have a bronze plan, your premium is low, but you pay more out of pocket for any healthcare services. If you have a platinum plan, your premium is higher than for other tiers of coverage, but your insurer pays a bigger share of your healthcare costs. There is no right or wrong metal: Employees should make the choice based on how much healthcare you typically use and how financially comfortable you are.

If you’re looking only for protection against a catastrophe, the marketplaces also offer catastrophic health plans, which have low premiums but a high deductible. Aside from certain preventive services that are usually free, you’d have to pay that deductible before your insurance would begin to pay anything. To qualify for a catastrophic health plan, you have to be under age 30 or have a hardship exemption from the requirement to have health insurance.

See also: In-network deductibles rise 50% in 2016

Broad and narrow networks
Another factor to consider is the size of a health plan’s network. A network is the group of providers such as doctors, hospitals and labs, who have contracted with your insurer to accept the insurer’s rate as full payment for their services. Receiving care from network providers is always more affordable than going out of network. So take a good look at the networks of the plans you’re considering.

By law, health plans have to maintain a network that is “adequate” to deliver the benefits they promise. However, plans differ in how they do this. Some offer their members a broad network, with a large choice of providers while a narrow network offers a more limited choice. Narrow-network plans may have lower premiums than those with broad networks.

You have to decide for yourself how important the size of the network is to you. For example, you may have a personal relationship with one or more doctors, and want a network that includes them. Or, you may have a number of medical conditions, and want to ensure the health plan’s network is broad enough to include all the specialists whose services you may require. But, if you’re in good health and don’t have a regular relationship with a doctor, a narrow network may be worth considering.

Flexibility in obtaining care
Do you want the freedom to go to specialists without having to get approval from a primary care physician first? Or would you rather just visit your PCP when you’re sick and let that doctor decide if you need a specialist? Do you want to be free to go to an out-of-network doctor if you think you can get better care that way, or are you content to stick with in-network doctors? The answers to those questions will help determine what type of health plan is best for you.

There are four basic types of health plans, each offering different levels of flexibility in how you can obtain care. In a health maintenance organization or point of service plan, you usually choose a PCP who decides if you need to see a specialist. If you do need a specialist, the PCP refers you to a provider in your network. If you decide you want to see a provider outside your network, you’re free to do so, but in an HMO you’ll have to pay the full cost. (Health plans often make an exception for out-of-network emergency care.) A POS plan will pay part of the cost of going out of network, but the share they pay will be smaller than if you stayed in network.

Two other plan types allow you to see specialists without a referral from a PCP. An exclusive provider organization allows you to see any provider you want in your plan’s network, without a referral. But you’ll pay the full cost if you see a provider outside the network. Maximum flexibility comes with a preferred provider organization, which lets you see any provider you want without a referral, in or out of network. But, if the provider is out of network, your share of the costs will be higher than if you stayed in network.

When deciding among plan types, consider the costs. An HMO, for example, gives you less flexibility but is usually less expensive than a PPO.

Getting government help
If you do use the marketplaces to buy a plan, you may be eligible for financial assistance. To apply, use the state or federal marketplace. If your income is under certain limits, you may qualify for public health insurance through Medicaid or the Children’s Health Insurance Program. If you’re age 65 or older, you can enroll in Medicare. If you’re an immigrant, you may be eligible to use the marketplaces or enroll in public health insurance programs.

What if you miss open enrollment?
Even if you miss the open enrollment period, don’t despair. Most employers let you make changes to your health coverage for certain life events, such as marriage, childbirth or loss of coverage under a spouse’s plan. The marketplaces allow “special enrollment periods” for similar kinds of events.

Still, open enrollment season is the best time to think about what you want from a health plan. The time to do that thinking is now.

Register or login for access to this item and much more

All Employee Benefit News becomes archived within a week of it being published

Community members receive:
  • All recent and archived articles
  • Conference offers and updates
  • A full menu of enewsletter options
  • Web seminars, white papers, ebooks

Don't have an account? Register for Free Unlimited Access