Open Enrollment – Choosing the Plan That’s Right for You


It’s Open Enrollment season and Consumers for Quality Care wants you to be prepared for potential changes to your insurance plan.

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There is one constant that Americans can rely on: health care coverage, and the rules and policies surrounding it, are constantly changing. While more people have health care coverage today, too many face steep challenges in accessing the care they need due to the constantly changing dynamic of the industry.

When examining insurance options, it is often hard to find information about what health plans do and do not cover, including the providers you can see and the costs you will incur. This can lead to surprise medical bills, coverage denials and increased costs. Whether these changes are the result of public policy, insurance rules or levels of coverage, it is crucial when selecting your health coverage to take note of what best serves your specific needs. Consumers for Quality Care wants to help you prepare for potential changes to your insurance plan.

During this open enrollment season, whether your health insurance is through your employer, Healthcare.gov, Medicare or another source, here are some of the potential changes and issues you should be on the lookout for:

  • Emergency Department Policies
    Some insurers are instituting policies that would force their policy-holders to pay for an emergency room visit if it is later deemed a non-emergency. Making health care decisions in a non-emergency situation can be trying enough. Making them in a split-second is an even greater challenge.
    What to Look For: Note which insurance companies are implementing this policy and in which states. If you select a policy with this plan in place and encounter issues with emergency department coverage, many of the affected states have established hotlines through their insurance commissioners to file complaints.
  • Narrow Networks
    Narrow networks were created to bring lower-cost health insurance plans to Affordable Care Act (ACA) markets. These plans generally limit coverage to fewer than 25 percent of providers in a given market. A recent study found that one of the tradeoffs for lower costs may be less access to mental health coverage, with only 19 percent of non-physician mental health providers covered by narrow network plans. Another recent review by researchers at the Perelman School of Medicine at the University of Pennsylvania found that narrow network insurance plans regularly exclude the nation’s best cancer research and treatment institutions from their coverage.
    What to Look For: With all health care plans, it’s important to check which providers are in-network to ensure that your primary care and specialty doctors are included. Ideally, information should be easily accessible on insurance company websites and searchable by diagnosis, but it can sometimes be difficult to determine which physicians are in-network. Don’t be afraid to call the insurance providers or your physician to get the information you need to make the right decision.
  • At-the-Counter Prescription Prices Due to Tiers and Formularies
    Consumers often don’t know that different insurance plans can mean different prices for the same treatment, even when the plans come from the same company. Insurance companies utilize formularies and “tier” prescriptions into categories, primarily based on cost. This can mean that the same treatment through one plan is double the cost than it is on the other because it falls into a higher tier. It also means that some prescriptions may not be on the formulary at all and patients will have to get special permission before those drugs are covered.
    What to Look For: Consumers, particularly those already taking specific treatments, should consult prospective plans’ tiers and 1) make sure their drug is covered and 2) see how the price is impacted based on its tier.
  • Co-pays and Co-insurance
    Too often, these two terms are misunderstood or even confused with one another, leading to greater out-of-pocket costs for consumers. A co-pay is a set amount a patient must pay when seeking a service. Co-insurance is a set percentage of the cost of treatment that the patient must pay. For example, if an X-ray costs $500, and one plan has a $50 co-pay while the other has a 20% co-insurance for X-rays, the price paid by under the latter is $100. Obviously, the amount borne by the consumer increases incrementally with the cost of treatment. In the case of co-pays, the cost remains the same for all services that have a particular co-pay.
    What to Look For: Most plans will denote co-pays or co-insurance in the plan summary. Make sure you understand the terms correctly and choose plans that make the most sense for your needs and budget.
  • Coupons to Help Pay for Medicines
    We are hearing more and more about health plans and Pharmacy Benefit Managers (PBMs) making it harder for patients to take advantage of coupons that help them afford their prescription drugs. Some patients are finding out that by using a coupon, the full plan-assigned cost sharing for their medication no longer counts towards their deductible or cap on total out-of-pocket costs. In some cases, these patients never get through the deductible and then their coupons run out of money before the end of the year—leaving the patients with unaffordable cost sharing when they try to fill a prescription at the pharmacy.
    What to Look For:If you currently use a coupon to help pay for your prescription drugs and you are thinking about changing plans, you should check whether the use of a coupon will make it harder for you to reach your plan's deductible or the maximum you have to pay out-of-pocket. Contact your plan to find out if you will face any restrictions.

It is important to note that Healthcare.gov and the state marketplaces are open for business, but Open Enrollment is shorter this year, running from Nov. 1 to Dec. 15. Make sure you shop around to find the best plan for you — premiums will likely go up but subsidies will go up too, so you may still be able to find a good deal. Keeping these tips in mind will help you make an informed decision about which health plan makes the most sense for you and your family.

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