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Wading through the health insurance landscape can be tricky and overwhelming as you’re starting your journey in the U.S. No matter your age or marital status, it’s important you have some level of health insurance to take care of you and your family in case of illness.
Towards the end of the year is what’s known as open enrollment season — a specific time when you can sign up or change your health insurance plan.
Your employer (or your spouse’s) typically provides an employer-sponsored group plan, but there are other options. These include such as the ones provided by marketplace plans which is a service provided by the federal government that helps U.S. residents enroll in more affordable health insurance plans (if you’re self-employed or aren’t currently employed) and private exchanges, which are plans offered through individual health insurance companies.
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Whatever your healthcare needs are, there are some important choices to make that will have an affect on how much you pay and the quality of your medical care coverage. Keep in mind that health plans in the U.S. typically don’t cover expenses outside of the U.S. for you and your family (even if you’re traveling) — you may need to look into travel insurance and you don’t need to worry about open enrollment season to sign up for a policy.
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Here’s what you need to know about open enrollment, including what it is, basic health insurance terms and how to choose a plan specifically when you’re residing in the U.S.
When is Open Enrollment?
Open enrollment is a specific time period when you can start, change or cancel a health insurance plan — it’s typically in Quarter 4 of each year, but could differ if your health insurance plan is through your employer. Once you make a change, it’ll typically lasts for the next full year until the next open enrollment begins.
However, there are exceptions to the rule. Individuals may be entitled to a special enrollment period as long as you fall under what’s considered a qualifying life event.
This exception includes:
- You moved to a new ZIP code or county
- Had a new baby or lost a dependent
- Got married, divorced or became a widower
- Lost or gained new employment
- Becoming a new U.S. citizen or gaining lawfully present status
If any of the above situations apply to you, you generally have 30 days after a qualifying event to enroll in a plan through an employer-sponsored plan or up to 60 days on the individual marketplace.
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Understanding Basic Health Insurance Terms
Before choosing a plan, understanding some basic healthcare insurance terms can make it easier for you to compare plans.
Here are a few you may come across as you’re browsing through your options:
Premium - The monthly amount you pay for your health insurance plan
Deductible - The amount you need to pay before your health insurance kicks in. For example a $1,500 deductible means you need to pay that amount before your health insurance covers your cost. Numbers are typically on an annual basis, but check with your provider to make sure.
Network - A group of doctors, hospitals and clinics that provide its members health care services. Some insurance plans only provide in-network services and some both but it can come with a higher premium.
Co-pay - What you need to pay to see a doctor. This amount might not count towards a deductible.
Co-insurance -A percentage of what you’ll need to pay for health care services after you reach your deductible.
Out of pocket maximum - The amount you’ll pay at the most per year for healthcare before your insurance kicks in. This includes your co-pay, co-insurance and deductible.
HMO - This term stands for health maintenance organization, a type of healthcare plan. You typically get a lower premiums but you may be limited to a restricted network.
PPO - Also known as a preferred provider organization, it’s another type of healthcare plan but tends to have a larger network and members may be able to use out-of-network providers.
POS - A cross between HMO and PPOs, a point of service plan gives you the opportunity to choose between either HMO or PPO services when visiting a doctor.
EPO - A exclusive provider organization is one of the most restrictive plans because you are not allowed to use out-of-network care unless it’s considered an emergency.
HDHP - Standing for high deductible health plan, they typically high higher deductibles and can have both in- and out-of-network providers. These plans allow for a health savings account which gives the opportunity to contribute pre-tax dollars toward qualified medical expenses.
Exclusions - These are the things that your plan won’t cover, such as cosmetic surgery, alternative medicine or pre-existing conditions.
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How to Choose a Plan
You typically choose a healthcare plan through your employer, individual health insurance plans or via marketplace plans (e.g. Healthcare.gov and state exchanges). Most people go through their employer because it’s the simplest and typically most cost effective option (including spouses and dependents). However, many of the plans found through the marketplace can be the same ones offered by employers and may have subsidized premiums depending on your income.
As for where to select your healthcare plan, start with your employer first — your HR department should be able to provide you with detailed information about your benefits, including written materials and benefit plan meetings. If you don’t think their plans are best suited for your needs, then check out what the marketplace offers. Ask for help if you need to understand your insurance options as you can’t change your plan until the next year once you make a decision.
Choosing the right plan for you and your family depends on your lifestyle, including your preferred doctors and any medical equipment or medicine you take on a regular basis.
Take stock of our healthcare needs this past year, even if you weren’t living in the U.S. If you found that you visited doctors pretty regularly or need to take medicine regularly, you may want a more flexible plan so you can choose in- and out-of-network doctors. Or you decide you want to go with an HDHP because you don’t anticipate needing to visit the doctor apart from your annual physical.
Also look at any upcoming changes to your situation this year. Maybe you plan on starting a family, or your spouse was recently diagnosed with a chronic illness. Then do your research by looking at the reviews on health insurance providers and comparing plans to make sure you get the correct amount of coverage. Do calculations when comparing plans to see how much you need to set aside for your premium and deductible.
Before changing plans, check to make sure that your primary care provider and hospital are still part of your plan’s network. It’s especially important to check if you plan on switching insurance companies or health plan.
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Protect The Health of You And Your Loved Ones
All of the above can be a lot of information to take in. Take it one step at a time and ensure that you understand what your plan covers by speaking with your HR representative or contacting the plan provider directly. While it can be overwhelming looking through confusing terminology and comparing plans, it’s worth taking the time to pick the perfect plan for your needs. After all, it’s you and your family’s health at stake.