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Why you should care about open enrollment

October 13, 2016 | UCI Health
What is open enrollment

OK, so it's not as exciting as the baseball World Series or the presidential debates. But open enrollment — the time you choose your health coverage — is still something you shouldn't miss.

Open enrollment is a period of time, typically several weeks in the fall of each year, when you have the freedom to change your health insurance without incurring any type of penalty.

We asked UC Irvine experts Dr. Manuel Porto and Glenn Rodriguez to explain why open enrollment matters and what you should look for. Porto is president and CEO of UCI Health Physicians & Surgeons. Rodriguez is a UC Irvine human resources healthcare facilitator. They explain the nuts and bolts of open enrollment:

What is open enrollment?

Think of open enrollment as a shopping season for healthcare. This is the period when the store is open and you can go in, look around and make your purchase. There are three basic types of insurance coverage, and each has its own open enrollment period dates and deadlines:

What happens if you fail to make any changes during open enrollment?

Doing nothing means that whatever plan you have in place for the current year will automatically roll over into the next year. After open enrollment, you won't be able to make any changes to your health insurance unless you experience a "life-changing" event, such as:

  • Losing a job
  • Being dropped from a parent’s plan because of age
  • Having a child
  • Marriage 
  • Divorce

Flexible spending accounts do not roll over 

However, one part of your coverage that won't automatically roll over is a Health Flexible Spending Account (FSA). This is a financial decision that you must renew each year. (A Dependent Care FSA also must be renewed each year.) It's a good idea to review your current health plan and health spending account and think about whether they will suit you and your dependents for another year.

It's likely that your current plan will undergo some changes for the coming year, and your premiums and out-of-pocket costs may change. Your preferred providers may have changed networks. It’s important to consider these factors in choosing to continue coverage or start new coverage.

What decisions must you make, and for whom?

You should choose coverage for yourself and any dependents who need your insurance. Think about the level of care you and your dependents need. No one has a crystal ball, but if you’ve been seeing your primary care doctor annually, you should have an idea of the care you’ll need going forward. Make sure you opt for a plan that provides that coverage, such as for maternity care, an elective surgery you’ve been considering, or prescription drugs.

If your family’s health is stable, you might choose a plan with a very high annual deductible and co-pays. But if a family member requires ongoing therapy, surgery or an inpatient admission, you may want to choose a plan where your out-of-pocket costs are not as high.

What are the different types of plans for private or employer-offered insurance?

There are two types of health insurance plans:

  • PPOs (preferred provider organizations). In general, consumers typically pay more for PPOs but have a broader choice of preferred providers, specialists and care centers, compared to HMOs.
  • HMOs (health maintenance organizations). HMO premiums tend to be lower, but you must seek care from doctors in the HMO or pay out-of-pocket to go outside the network.

What should you look for in a health plan?

The tendency is to look only at whether their primary care provider is in the covered network. It’s also important that top-tier specialists and facilities are in the network. It’s something to discuss with your primary care physician.

UCI Health’s grouping of primary care and specialty physicians together in convenient locations across the county allows for seamless referrals, sometimes even within the same suite of offices.

What factors do people tend to overlook when choosing a plan?

Many consumers don't understand three basic terms that impact their coverage and their wallets:

  • Deductibles. Deductibles apply to PPO plans but not HMOs. The deductible is the amount you pay for covered healthcare services before your insurance plan starts to pay. For example, you may have to pay for the first $3,500 of your healthcare costs before your coverage kicks in. Some health plans are called "high-deductible" plans because they carry deductibles that can be as high as $6,500. However, the monthly premiums for these plans tend to be lower.
  • Co-payments or co-insurance. A co-payment is a term used in HMO plans. It's a small fee you pay at the start of every healthcare visit. Co-insurance is a term used in PPO plans. It's a fee you are billed for after your healthcare visit and is typically a percentage of the cost of the visit.
  • Out-of-pocket costs. The out-of-pocket cost is the maximum amount of money you'll need to spend for healthcare for the year, not including premiums. This amount is set in order to keep plans affordable should a catastrophic event occur that results in hundreds of thousands of dollars in medical costs.

Can I choose UCI Health doctors?

UCI Health contracts with most major medical plans and you’re likely to find your current provider or select a new, highly qualified provider in our large network of primary care physicians and specialists. Plus we’re expanding our network throughout Orange County, including in the cities of:

We have more than 100 physicians recognized as the “Best Doctors in America” and nationally recognized programs in nursing, as well as cancer, high-risk obstetrics, neonatal, digestive disease, stroke and trauma care. Our SeniorHealth Center has some of the few board-certified geriatric specialist physicians in Orange County.

And our hospital, UC Irvine Medical Center, has been on the U.S. News & World Report list of America’s Best Hospitals for 16 consecutive years, recognized this year for orthopaedics and for ear, nose and throat specialties, and is ranked highest in Orange County.

Do Medicare participants need to worry about open enrollment?

Yes. While you can choose to stay with your existing plan, most Medicare plans also undergo changes from one year to the next. There are several parts to Medicare. Basic Medicare — parts A and B —covers hospitalization and physician services. Part D covers pharmacy. You can also purchase Medicare Supplemental Insurance to help pay for some of the costs that Medicare doesn’t cover.

Many insurers offer Medicare Advantage plans, known as part C, that combine parts A, B and D — often for one monthly price. A number of Medicare Advantage plans function like HMOs.

If you’re approaching Medicare eligibility age, you should investigate your options.

Once you've enrolled in a Medicare plan, there are limitations on switching to plans — for example, switching from a Medicare HMO to a Medicare PPO. It's important to shop thoughtfully when first selecting your Medicare coverage and then examine your options carefully if you want to make changes from one year to the next.

What about insurance offered under the Affordable Care Act?

If you are not covered under an employer plan or Medicare, or if you want to opt out of employer coverage, you can go to healthcare.gov to purchase insurance. If you are laid off from your job, you can also seek coverage at healthcare.gov instead of opting for COBRA insurance coverage through your employer.

Healthcare.gov typically includes several types of plans from a number of insurance companies. You'll find a range of fees, co-pays and coverage, and the website makes it easy to compare your choices. There's also an online tool to help you find out which doctors and hospitals are part of each plan.

How long can parents cover a child?

Under the Affordable Care Act, you can now cover children up to age 26.

If your child is in college and is offered a student health plan, should you continue to cover your child on your private plan?

This is a personal decision. You will need to compare the costs and coverage of the student health plan to the costs and coverage of your private insurance. In some cases, it may make sense to have your child covered under both plans. Keep in mind that different colleges have different rules about student health insurance. Coverage requirements also vary by state. Examine the student health plan carefully and ask questions before making a decision.

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