Picking the Right Health Product During Open Enrollment


Senior Attorney

By Dena Mendelsohn on Tuesday, November 17th, 2015

It’s open enrollment time for millions of Americans who purchase individual health insurance (and for many more who get insurance through their employer). Picking a health insurance plan should be a part of everyone’s annual healthcare routine, wherever they get their plan.  Consumers Union has put together some simple tips for people purchasing a plan through Covered California – but these are questions to keep in mind for anyone choosing a health plan.

  1. Consider making a switch instead of relying on auto renewal.

If you bought your health plan through Covered California and do not want to change it, you will be automatically renewed into the same plan you had in 2015 (with some limited exceptions). Although being automatically renewed seems like an easy option, it might not be the best choice for you. For most people purchasing from Covered California, the options have changed enough that it is worth shopping around and comparing the 2016 plans.

  • Re-check your plan networks. If you stick with your current plan, you may discover the providers in your network have changed.
  • Review how much financial assistance (in the form of tax credits) you’re eligible for in 2016. If you received a premium tax credit in 2015, it has likely changed for 2016. You may find that a plan that was not affordable last year is now an option for you.
  • Consider if you are in the right metal tier. You can apply your premium tax credit to whichever plan you prefer in 2016. If you are eligible for cost-sharing reductions, you can only get them if you enroll in a Silver plan.
  • Check to be sure your tax credit is correct – If your income or a family member’s income will change in 2016, the financial help you are eligible for might be different. It’s worth taking a second look to make sure you get the best plan for 2016.
  1. Compare the costs

When researching your plan, don’t just look at the monthly premium. That’s only one element of the overall cost of the plan. It’s also important to take a close look at the deductible and what is known as “cost-sharing”: co-payments (or “co-pays”), co-insurance, and out-of-pocket maximum. It may seem more affordable to buy a health plan that has a low monthly premium, but look also at how much you will have to pay each time you visit the doctor or have to buy prescription drugs.

  • Consider any financial help for which you qualify – depending on your income, you may be eligible for premium tax credits to help lower the cost of your monthly premium. These premium tax credits are only available if you get your health plan through Covered California.
  • You may also be eligible for cost-sharing reductions (co-payments or co-insurance – discounts that lower the amount you have to pay when you visit the doctor or purchase your prescriptions) depending on which tier plan you choose. Cost-sharing reductions lower your costs, but only if you buy a Silver plan through Covered California.
  • Be sure you understand the difference between co-insurance and co-payments. We have a fact sheet that helps explain the difference.
  1. Know your network

Your provider network is a list of providers that have contracts with a health plan. Providers are doctors, hospitals, clinics, labs, pharmacies, and others you go to for medical care. The network will depend on what plan you purchase. Be sure you consider the following:

  • If there are specific doctors you want to see in 2016, check which health plans include them in their networks. Each plan is required to have an online provider directory you can use to search for your providers.
  • Confirm with the health insurer and your provider’s office that they are going to be in the plan’s network for 2016. Sometimes the online provider directory has not been fully updated to show providers for the upcoming year.
  • Networks vary among health insurance carriers and insurance products. Make sure you confirm that the name of the plan on the provider directory matches the name of the plan you are considering.

Getting care from a provider outside of your network could be a costly mistake: you might end up paying much higher co-payments or co-insurance or, worse, paying the whole bill yourself.

The type of plan you purchase–whether a PPO, HMO or EPO–will affect how you access care. Our fact sheet on why networks matter explains what it means to be “in network” and the costs involved if you go to doctors or hospitals that are not in the network.

  1. Learn more about the quality of plans

Because Covered California defines the medical benefits of plans sold on the state Marketplace, the decision about which individual health plan to choose on the state Marketplace may come down to provider network and preferred insurance plan. Those buying on Covered California can consider ratings available through the Quality Rating System, which are based on members’ reported experiences with the plans.

Consumers with employer-sponsored health insurance will have more variables to consider because their plan design is not standardized. In addition to comparing medical and prescription drug benefits, consumers going through open enrollment with their employer may also wish to consider quality ratings for the plans available to them. The California Office of the Patient Advocate recently released the newest edition of its Quality Report Card, which evaluates non-Covered California plans. This tool is designed to assist Californians in comparing health plans (and medical groups) latest quality data available. In addition to using the tool to compare health plans, consumers can compare plans based on specific health topics of concern to them.

For more information, check out Consumer Report’s health insurance information website, this blog post on how to use your insurance, and Covered California’s Shop and Compare Tool, which assists Californians considering their options on the state’s marketplace.

One response to “Picking the Right Health Product During Open Enrollment”

  1. Health Plan says:

    The Best health plan for you

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