03 Nov 2023 Open Enrollment FAQ
Open Enrollment 101 for
Individual and Family Plans
As we enter into the fall season, you are likely to hear friends and family talk about deductibles, co-pays, and health plans. That’s right, it’s open enrollment time! But what exactly is open enrollment and what information do you need to know? Our open enrollment guide walks you through the basics so you can choose a plan that’s right for you.
What is open enrollment?
Open enrollment is a specific time period each year when individuals and families can enroll in or make changes to their health insurance benefits. (This is for individuals and families who purchase plans on their own, not through an employer.) The only other time changes can be made to individual and family plans is if you experience a qualifying life event.
What is a qualifying life event?
A qualifying life event, or QLE, is defined as a change in your living situation that can make you eligible for a special enrollment period, allowing you to enroll in or update your health insurance outside the regular open enrollment timeframe, but within a specified time surrounding the QLE.
A QLE might include one of the following:
- Birth/adoption of a child
- Death in the family
- Move to a new location
- Involuntary loss of previous coverage
When does open enrollment occur?
Open enrollment typically occurs in the fall. The 2023 individual and family health insurance open enrollment period is from November 1 to January 15 in most states.
What does a health insurance plan cover?
Under the Affordable Care Act, plans must provide at least 10 essential benefits:
- Preventive and wellness care, including chronic disease management
- Ambulatory or “outpatient” services, such as blood tests and biopsies often done in a doctor’s office
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services
- Prescription drugs
- Rehabilitative services and devices
- Laboratory tests
- Pediatric services, including oral and vision care
Insurance plans may also offer additional benefits beyond those that are legally required. You can find this information on each plan provider’s website.
Important Questions to Ask When Choosing a Plan:
Are your doctors and hospitals in the plan’s network?
Check to see if your preferred primary care or specialist provider and the pharmacy near your home are included in the plan’s network. If they aren’t, you may have to pay for some or all of the costs of services, treatments, or medications.
How much is the monthly premium?
Premiums are the amount you pay an insurance company for coverage, whether or not you use medical and pharmacy services. This does not include co-pays, deductibles, and other costs, so you’ll want to consider those as well.
What is the plan’s deductible?
A health insurance deductible is the amount you pay for covered health care services before your insurance plan starts to pay. A good rule of thumb is plans with a high deductible will most likely have a lower monthly premium, while plans with lower deductibles often have higher monthly premiums.
What are the copays or coinsurance costs?
Depending on your plan, you may be responsible for out-of-pocket expenses even after you reach your deductible. These can include:
- Coinsurance: a percentage of costs you must pay for a medicine or service, or
- Copay: flat fees you are required to pay for prescriptions or covered services
Are your prescriptions covered?
Each insurer has a formulary, or list of medicines, covered by the plan. However, if your prescription is not included, you may have to pay extra. If you take a medication on a regular basis, it’s smart to confirm that it’s covered by your insurance.
What if I don’t enroll?
If you don’t enroll in an ACA-compliant health insurance plan by the end of open enrollment, your buying options will be limited until the next open enrollment starts, usually several months away.
So, it’s best to enroll sooner rather than later! Health insurance protects you from unexpected, high medical costs and offers you peace of mind. Open enrollment is a great opportunity to review your current health insurance and research plan options that fit your needs and budget for the coming year.
To learn more about coverage available in Eastern Wisconsin from Common Ground Healthcare Cooperative, go to commongroundhealthcare.org or call 855.494.2667.
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