The healthcare insurance information you need to know during open enrollment, and all year long.
It’s fall again. Leaves are changing. It’s back-to-school time and kids are facing new classes, teachers, and classmates. Adults are doing something almost as scary: braving this year’s health benefit options.
It can be intimidating, knowing the choices you make now will decide the healthcare options and costs for you and anyone on your plan, for the whole next year.
So no pop-quizzes here. Just five of the toughest questions we get, below, and straightforward answers. We hope this makes enrollment feel less like a test—or at least, like an easy one.
1. Copay, Coinsurance, Deductible, Premium… so many syllables! What do these words even mean?
Jargon is the worst. Let’s put this in real English for you:
- Premium. Your premium is like rent: it’s the amount you pay for your health insurance every month.
- Copay. Your copay is the amount of money ($20, for example) you pay for any doctor visit or healthcare service covered by your insurance.
- Deductible. Your deductible is just the amount of money you’ll pay towards doctor visits and other healthcare services yourself, before your insurance plan starts to pay. Plans have different deductibles. You “meet” your deductible when you have spent that amount on healthcare services.
- Coinsurance. Coinsurance is the percent of costs of doctor visits and other healthcare services you’ll pay after you’ve reached your deductible and your insurance plan has started to pay.
It’s a lot. Here’s an example. Say you get a $3000 medical bill. Your plan has a deductible of $2000 and coinsurance of 20%. You’ll pay $2000 (“meeting” your deductible), and have $1000 still left to pay. Of that $1000, you’ll pay 20% and insurance will pay 80%. Your final total: $2200. $2000 deductible + $200 coinsurance (20% of $1000 =$200).
2. How do I choose the most cost-effective plan?
Unfortunately, it’s not just about the lowest monthly costs, or even lowest deductibles. Best guesses are your best bet. Jot down anything you can think of you might need in the upcoming year or any changes you anticipate. Here are some helpful questions:
- Do you imagine next year will be about the same as last year as far as your healthcare needs?
- Do you have any anticipated large medical expenses in the next plan year, such as surgery, pregnancy, or chronic conditions that require many appointments/tests? (If you have conditions you need to manage or high cost medical expenses, a PPO/ HMO may be more cost effective in the long run.)
- Or are you healthy and engaging mostly with preventive care? (Then you might consider a High Deductible Healthcare Plan, or HDHP.)
- Are there screenings or vaccinations that are now recommended for you?
3. If I switch plans or health insurance companies, will my doctors still be in-network?
Honest answer, it could take a few calls. But it’s worth the time, including any time spent on hold, to get the right answer. Call your doctor’s office or your health insurance company. They can check and confirm first-hand whether or not your doctor will still be in-network.
We suggest calling again at the beginning of the year. It’s rare, but sometimes things change and doctors change which healthcare insurance they accept at the last minute. Even easier: clients of Included Health who have our Open Enrollment Support service can use the app to quickly check if their doctors will remain in-network.
4. What are healthcare spending accounts and what kinds are there?
Healthcare spending accounts are a great way to save money on medical expenses. There are three types, explained below. In two of them, you choose a set amount to deduct from your paycheck every month, pre-tax. The third is a fund that your employer puts money into on your behalf.
In all three, the money in these accounts is not taxed, which means that if you pay for expenses using these accounts, you save around 30%.You can use this money to pay for copays, deductibles, and other medical expenses. You can also use it for vision expenses, sunscreen, bandaids, pain relievers and more. Many online-retailers have special HSA and FSA ‘stores’.
Here are the three types of healthcare spending accounts, with some of their pluses and minuses:
- Health Savings Plan (HSA): A savings account that you own.
You decide how much to put into the plan every month, and that money goes into the savings account, tax-free. You can deduct these HSA contributions on your taxes. Employers can also contribute to your HSA. Rules for what you can spend it on can be complicated and they are only available if you have a high deductible health plan (HDHP). The money rolls over from year to year and if you leave, you keep the account.
2. Flexible Spending Account (FSA): A savings plan owned by your employer.
An FSA is like an HSA: you decide how much to put into the account, the money goes in tax free, and your employer can also contribute to the FSA. But you cannot deduct this money from your taxes. On the plus side, the account can be used for many types of health insurance plans, not just a high deductible account that an HSA. If there’s unused money at the end of the year, you can: 1) Get 2.5 more months to spend the left over money, or 2) Carry over up to $615 to spend the following year.
3. Health Reimbursement Account (HRA): An account funded by your employer, on your behalf.
With this one, money is not deducted from your paycheck. Your employer chooses which medical expenses the money can be used for and reimburses you with tax-free dollars for those expenses. Unused amounts can be rolled over to use the next year. You lose any money in the account if you leave the company.
5. Once I make my healthcare plan decisions, can I change them during the year?
Open enrollment is the time to check your work, change your answers, make any adjustments you’d like. Then it’s pencils down. After Open Enrollment ends you’re going to need a Qualifying Life Event (like loss/gain of coverage, marriage, or new baby) to make any changes.
So that’s healthcare plan enrollment, in a nutshell. We hope that it helps enrollment feel less testing, so you make the best health benefit decisions for you. If you need a refresh on more healthcare terms, check out our comprehensive healthcare glossary guide to help you navigate your health plan blog. Have a great year.
Authors: Kayla Cooper, Makayla Long, Holly Finn, Included Health
About Included Health
Included Health is a new kind of healthcare company, delivering integrated virtual care and navigation. We’re on a mission to raise the standard of healthcare for everyone. We break down barriers to provide high-quality care for every person in every community — no matter where they are in their health journey or what type of care they need, from acute to chronic, behavioral to physical. We offer our members care guidance, advocacy, and access to personalized virtual and in-person care for everyday and urgent care, primary care, behavioral health, and specialty care. It’s all included, all the time.
Interested in learning more about how you can offer all included care to your employees? Contact a member of the Included Health sales team to start a conversation. Included Health members can log in or activate their accounts to get started.
About the author
Editorial Team
Our Editorial Team is composed of our leaders, clinicians, and care coordinators, as well as other Included Health employees, all who are working to raise the standard of healthcare for everyone. Together, they combine decades of subject matter experience across all fields of healthcare.