Four Questions to Help You Choose a Health Insurance Plan
Open enrollment is time to enroll, renew or change health plans
Open enrollment is time to enroll, renew or change health plans
Choosing the right health insurance plan can be a hard task when there are so many options. This is especially true during open enrollment, which typically occurs in the fall for most health insurance plans.
During this period, people can review their health care coverage and make changes if needed. For example, they can switch to a plan that fits their medical or financial needs better. The deadline for these decisions makes the process urgent.
Selecting the right health insurance plan for you and your family involves asking some key questions. Consider these four questions:
1. Who is paying for my insurance?
Health insurance can come from different sources. These sources depend on the type of coverage and who is insured. It can come from your employer, the government or you can buy it yourself.
Each payer has different plans. These plans vary in coverage, provider networks and costs.
Employer sponsored: Most people get health insurance from their job or their spouse‘s job. Employees choose from plans offered by their employers, who set the open enrollment periods.
Open enrollment usually takes place in the fall. This lets benefits start at the beginning of the new year. If you want to change your plan or switch, this is the time to look at your options.
You can change your health plan at other times if you meet special rules. These are known as qualifying life events. Examples are getting married, having a baby, moving or losing your coverage.
When you start a new job with health insurance, you usually have a special enrollment period. This period lasts 30 to 90 days from your start date. During this time, you can sign up for health benefits. This is not the same as the annual open enrollment period.
Self-employed: If you don‘t have job insurance or are self-employed, you can buy your own insurance. You can get health insurance from private companies or through a health insurance marketplace or exchange.
In California, you can use the health insurance exchange called Covered California. Here, you can shop for health insurance, compare plans and buy the one you like. The open enrollment period for 2025 runs from Nov. 1 and ends Jan. 31.
Based on your income, you might qualify for federal assistance. This support can reduce your insurance costs.
Medicare: If you are 65 or older, you can get insurance through Medicare. You can sign up for a Medicare plan or change your current plan. You can do this during the open enrollment period. This period runs from October 15 to December 7 each year.
2. What kind of health plan do you need?
Think about your health needs and budget when looking at different health insurance plans. Most health insurance plans fit into one of three categories.
Health Maintenance Organization (HMO) plans require you to use doctors and hospitals from a specific list called the “network.” Your costs are lower when you visit an “in-network” provider. If you go to one outside the network, your care may not be covered. You might have to pay the entire bill unless it is an emergency.
Your primary care doctor must refer you to specialists or other services. This is needed for the HMO to pay for those services.
Exclusive Provider Organization (EPO) plans are similar to HMOs. However, you might not need a referral from your primary care provider to see a specialist.
Preferred Provider Organization (PPO) plans have a network of doctors and hospitals. If you visit a doctor or hospital outside the network, your PPO may help with some costs. However, it will not cover as much as if you stay in the network. You do not need a referral from your primary care doctor to see a specialist.
Overall, PPO plans give you more choices of doctors and hospitals than HMO plans, but they also cost more.
HMO, EPO and PPO plans can vary a lot. It is important to read the details of each plan carefully.
3. What type of health care services do you need?
When picking a health insurance plan, think about your health needs. Do you have a chronic condition like diabetes? If yes, choose a plan that covers check-ups, medication and maybe specialist care.
Consider your lifestyle as well. If you are active and healthy, you may need less coverage. However, if you are at risk for health issues, you may need more.
4. What are costs?
Consider how health insurance costs impact your budget and access to medical care. These costs include premiums, deductibles, copayments and coinsurance. They directly affect your monthly and yearly expenses.
Premium is the amount you pay each month for your insurance. This cost is part of your total insurance expenses. Consider if you can afford the premium. Remember, lower premiums often mean higher out-of-pocket costs.
Deductible is the amount you pay out-of-pocket before your health insurance starts to pay. Generally, the higher your monthly premium, the lower your deductible.
Co-pay is the amount you pay for each doctor visit, prescription, lab test and so on. For example, you may have a $35 co-pay every time you see the doctor, regardless of your deductible amount.
Coinsurance is the amount you owe after your insurance plan pays its share. For example, your plan may pay 80% of a hospital stay and you pay 20%.
If you have questions about which plans include Scripps doctors and hospitals, call 858-465-4120. You can also visit our website to learn more about your health insurance options.