Open enrollment season (sometimes also called annual enrollment) is here, which means it’s time to pick a health plan for the upcoming calendar year. The open enrollment yearly period is usually in the fall when people can enroll in a health insurance plan for the next calendar year.

The 2022 Open Enrollment Period (OEP) begins November 1, 2021, and ends January 15, 2022, in most states. This time is especially important because your health plan choice determines what services and providers you’ll be able to access, how much you’re paying out of pocket, and more. 

While this process can be confusing, it’s a great time to reassess if your current insurance is working for you, and ask if making some changes could better your healthcare experience. If your company offers health insurance as a benefit, it’s part of your compensation for work, and your employer helps you pay for your insurance. So unless you have access to affordable coverage elsewhere, opting out or not paying attention to what health plan you’re choosing is kind of like not getting paid your full wages. It’s crucial to know that if you don’t select a plan during open enrollment, you will not be able to get coverage unless you experience a qualifying life event, or you are able to be added to a family member’s or partner’s plan.

It’s also important to check with your employer to see if this is an active or passive enrollment period for you. What does that mean exactly? Either you need to take action and select plans moving forward into the new plan year (active) or they automatically roll forward for you with no action needed (passive). Additionally, some employers require that you opt into or out of your HSA, FSA or other savings accounts regardless of active or passive enrollment status, so it’s important to know where you stand for the year. If you’re an employee whose company provides Included Health as a benefit, we’re here to offer you guidance. Our care coordinators are a quick call or email away. We’re happy to help you figure out whatever you need to choose the plan that feels best for your health goals. But for now, we’re here to answer some of the most common questions around open enrollment.

BASIC QUESTIONS AND ANSWERS THAT WILL HELP YOU UNDERSTAND POTENTIAL HEALTH PLAN PICKS DURING OPEN ENROLLMENT SEASON:

Q: What are premiums and deductibles?

A: Your premium is the amount that you pay every month in order to maintain your health insurance coverage. If your insurance plan is offered through your employer, usually your monthly premium is deducted automatically from your paycheck.

Your deductible is the amount that you must pay out of pocket before your insurance plan begins paying for certain services. Some services, like annual wellness visits or flu shots, are typically “not subject to deductible” (meaning, covered at no cost to you regardless of whether you have met your deductible). Some plans have an additional amount beyond the deductible called the “maximum out of pocket amount.” After the maximum out of pocket amount is met, health care services will typically be covered at no cost to you. Check your insurance plan documents for more information about your deductible, maximum out of pocket amount, and which health services are subject or not subject to your deductible.

(Note: More common healthcare terms are explained in detail in our blog, Included Health’s Glossary for Understanding your Healthcare)

Q: Can my spouse/family members be on my health plan?

A: Yes! Your premium cost will typically be different depending on whether you are only enrolling yourself, or whether you are enrolling a spouse and/or children as well.

Q: I am not married but have a long term partner, can I insure my partner along with me and will the premiums be a deduction before tax or after tax? 

A: Many employer-based plans will allow you to enroll a domestic partner (a partner to whom you are not legally married). You may be required to show proof of domestic partnership, such as proof of a shared bank account or shared lease/mortgage. Typically, premiums to cover a domestic partner are deducted from your pay on an after-tax basis. 

Q: What if my plan refuses to cover the services that I need?

A: Talk with your Human Resources representative to assess what is covered and not covered. Raising the concern will make the HR team aware of items outside of the coverage scope for contract renegotiations in the future. In some situations, you may be able to seek an exception with your plan – your Included Health care coordinator can support you if this situation applies to you!

Q: I got married/had a life event in November during open enrollment and made changes to my coverage. Do I still need to make open enrollment elections? 

A: Yes! Even if you have recently made changes to your coverage, you still need to enroll during open enrollment to have coverage for the following plan year.

Q: Will gender affirming hormones be covered by my plan? 

A: Potentially! Coverage varies by plan, but we’ll try our best to help you figure out getting the services you need under a specific plan. If you’re an Included Health member, it’s best to have a personal conversation with a care coordinator to figure out what is and is not possible. 

Q: Will my plan cover behavioral health specialists/therapists? 

A: Coverage varies by plan, but be sure to check for out-of-network coverage as well, since many therapists operate as out-of-network providers only. 

Q: Will my plan cover hair removal as part of my gender affirming care plan?

A: For needs like gender-affirming hair removal, coverage varies by plan. Be sure to check if non-surgical hair removal is covered, as well as pre-surgical hair removal. It’s important to check and see what criteria there is for coverage, and what the reimbursement rate is, since most hair removal providers aren’t able to bill insurance directly. If your provider can’t bill insurance directly, you will need to pay for the service first, then file with your insurance plan for reimbursement.

Q: Will my plan cover gender affirming voice lessons/therapy?

A: Again, coverage varies by plan. Some speech language pathologists are able to work directly with insurance, but most other vocal coaches are not licensed medical providers, and would require filing claims for reimbursement. Check to see what criteria is needed for voice therapy to be covered, and if there is any criteria for the provider.

Q: Which gender affirming surgeries are covered? 

A: Coverage varies by plan, but check to see what the criteria is for coverage for the specific surgeries that you are interested in (amount of time on GAHT or HRT, letters of support from mental health providers, etc). Additionally, take a look at out-of-network coverage if you are interested in working with a specific surgeon who is not in-network. If you’re planning a surgery, also consider the facilities (making sure that not just your surgeon is in-network, but the surgery center, attending operating room clinicians, anesthesiologists, etc).

Q: Is PrEP (pre-exposure prophylaxis to prevent HIV) covered under my formulary and, if so, what is my out-of-pocket cost?

A: Most health insurance plans are now required to cover at least one form of PrEP at no cost to you. Check your formulary to see which form of PrEP is covered at no cost. Currently, there are three forms of PrEP available in the United States: name-brand Descovy, name-brand Truvada, and generic Truvada (which may be listed in your formulary as “emtricitabine-tenofovir disoproxil fumarate”). If you are taking a form of PrEP that has an out-of-pocket cost under your plan, there may be manufacturer copay assistance cards available to reduce your out-of-pocket cost.

Q: What if I miss the deadline to enroll?

A: If you miss the deadline to enroll, you will not be able to enroll in your employer’s health insurance plan until the following plan year, unless you experience a qualifying life event such as getting married or having a baby.

Q: What is considered a qualifying life event?

A: 

• Marriage.
• Birth or adoption.
• Death of a spouse or dependent.
• Job loss.
• Job change (can vary by Employer).
• Retirement.
• Reduction in work hours.
• Relocation (can vary by Employer).

Q: How can a care coordinator from Included Health help me navigate open enrollment? 

A: We can… 

• Assess which providers are in/out of network based on your coverage options
• Answer questions about what services are available under a plan you may be considering
• Help you find health care providers to meet planned upcoming services
• And more!

Last but not least, here are some questions to ask yourself during the open enrollment process:

• What kinds of services might I want to plan ahead for? If I am covering a domestic partner/spouse or children, what kinds of services might they need over the next year?
• Which plans are accepted by my current health care providers?
• Am I comfortable with my current providers, or do I need to revisit who I receive care from?

Resources:

• Trans health insurance guide for ACA Marketplace plans (if you choose to opt out of your employer-provided plan) 
• LGBTQ+ healthcare bill of rights 
• National Center for Transgender Equality’s Health Coverage Guide

At Included Health, we strive to provide friendly and exceptional healthcare service to the LGBTQ+ community. Become a member today to receive more health and well-being updates from our care team. And please do not hesitate to contact us to #GetIncluded for your company, health plan, and community.