Helping you make sense of health care

Tips to help you choose a plan during open enrollment season
Couple reviewing documents together

Open enrollment season is here and many of you now have the opportunity to choose or switch to a new healthcare plan. Healthcare coverage is a way to make sure you and your family get the care they need at a reasonable cost. But wading through all the options can feel overwhelming. HMO vs PPO, On-exchange vs Off-exchange, deductibles vs copays – it’s understandable that choosing a healthcare plan can seem like throwing a dart in the dark.

However, as a healthcare service plan, we know how important choosing healthcare coverage can be. In fact, that’s part of our mission: to make sure every Californian has access to affordable healthcare worthy of our friends and family. Knowing your choices and your rights can help you stay covered when you need it and help manage costs in the face of unexpected illness or injury.

We’ll cover some basic things to keep in mind as you choose your healthcare coverage. Also, you can reach out to us directly if you have questions about our specific plans and what’s covered – especially now that the COVID-19 pandemic is shifting the ways in which people seek care.

Basics of healthcare coverage

Healthcare coverage helps to cover healthcare-related costs, usually for a monthly premium payment. Based on your specific coverage, you might incur other out-of-pocket costs – known as “cost shares” or “share of cost” – such as copays, deductibles, and coinsurance. It’s best to check with the plan’s customer service team to know exactly which services are covered at which costs, if any. Preventive care, which includes services such as annual wellness examinations, screenings, and immunizations, is often covered without any cost share.

How you obtain your healthcare coverage depends on a variety of factors, such as employment, age, income, and much more. Some common examples of where you might get coverage include:

  • Through your employer
  • Through Covered California, aka “On-exchange”
  • Directly through a healthcare plan like Blue Shield of California
  • Through a government-sponsored program like Medicare or Medi-Cal

Another common choice you might have to make is between an HMO (health maintenance organization) plan and a PPO (preferred provider organization) plan. With HMO plans, your primary care physician (PCP) is usually your main point of contact and coordinates your care team within a certain medical group. While these plans often have lower out-of-pocket costs compared to PPO plans, your choice in doctors, specialists, urgent care centers, and hospitals is usually more limited.

On the flip side, PPO plans usually offer you more choice in which doctor, specialist, urgent care center, or hospital you visit, but often have higher out-of-pocket costs. Your cost share will be higher if you see a doctor who does not participate in your plan’s network. So cost, frequency of care, and where you want to receive care will most likely inform whether you choose an HMO plan or a PPO plan.

And don’t forget dental or vision coverage. Some plans cover dental or vision, but some do not. Depending on your needs, you can choose a plan that combines the medical, dental, and vision coverage you need or purchase separate medical, dental, and vision coverage. If you get coverage through your employer or government-sponsored program, they will most likely have a say as to whether or not dental or vision is a covered benefit.

Planned healthcare costs

When estimating planned healthcare costs, consider what you might need to pay to take care of your regular physical, mental, and emotional health needs. You might also consider whether you are planning a lifestyle change. Will you be moving? Getting married? Having a baby? While you might not be taking on these responsibilities now, knowing that they could become a reality in the next year could inform your choice of health plan.

First, let’s learn some helpful terms to help you better calculate planned expenses.

  • Premium: the amount a member pays the healthcare company each month for their health coverage
  • Deductible: the amount a member pays each calendar year for most covered services before healthcare coverage begins to pay. Specific covered services, such as preventive care, are covered before a member reaches the calendar-year deductible
  • Copay: the fixed dollar amount a member pays for benefits after meeting any applicable calendar-year deductible
  • Coinsurance: the percentage amount a member pays for benefits after meeting any calendar-year deductible

It’s helpful to know that typically the higher your monthly premium is, the lower your cost share will be. However, if you get your plan through your employer, this might not necessarily be the case. But in general, someone who is healthy and rarely goes to the doctor might choose a plan with a low monthly premium and a higher cost share.

Plans with higher monthly premiums typically have a lower share of cost; though again, this might not always be the case, especially for plans offered through an employer. People who see the doctor frequently might choose a plan with a higher premium and lower cost share.

Finally, it’s good to explore what a plan will and will not cover. It’s important to know what kind of care you routinely need so you can choose a plan with those covered services.

Planning for the unexpected

Planning for the unexpected might seem like an oxymoron, but being prepared for unexpected healthcare costs is a important factor when choosing a plan.

First, let’s learn some helpful terms to help you better calculate planned expenses.

Exploring the cost share for specific services is usually a good idea when comparing plans. Some common services include:

  • Urgent care
  • Emergency care
  • Prescriptions
  • Pre-natal and pregnancy care
  • X-rays
  • Physical, occupational, and speech-language therapies
  • MRIs
  • Acupuncture
  • Chiropractic care
  • Mental health and substance use disorder care
  • Ambulance transport
  • Hospital stays

While the variety of healthcare plans and policies available to choose from during open enrollment might seem overwhelming, keeping this information in mind can help you narrow down the options and feel empowered to choose exactly the right plan for you and your family. And if you are still not sure which plan to choose, reaching out to the healthcare company directly, talking to your employer about your options, or speaking with a Medicare or Medi-Cal representative are some ways to make sure all your pressing questions are answered.

Understanding health care

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