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When choosing a health insurance plan, it’s important to understand some basic factors such as deductibles, in network vs out of network coverage, copay per different types of visits among others.
Open enrollment allows people to sign up for a new plan or make modification.
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About Open Enrollment
Open enrollment is a period of time each year when you can sign up for health insurance or change your plan (if your plan is provided by an employer, open enrollment is also an opportunity to disenroll if you no longer want the coverage). If you don't sign up for health insurance during open enrollment, you probably can't sign up for health insurance until the next open enrollment period, unless you experience a qualifying event.
What Types of Health Insurance Use Open Enrollment Periods?
Open enrollment periods are used for most types of health insurance, including:
- Medicare1
- Job-based health insurance
- Individual market health insurance (ie, coverage that people buy for themselves, as opposed to getting from an employer), as a result of the Affordable Care Act (enrollment windows apply both in the health insurance exchanges and outside the exchanges)
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When Is Open Enrollment?
Medicare open enrollment (for Medicare Advantage and Part D plans) runs from October 15 to December 7 each year, and there is a separate open enrollment period from January 1 to March 31 for people who already have Medicare Advantage.2 Note that the Medicare open enrollment periods do NOT apply to Medigap plans, which don't have an annual open enrollment period. Medigap plans are only available without medical underwriting during your initial enrollment period or during one of the very limited special enrollment periods that apply to those plans, although a few states have implemented rules that allow Medigap enrollees to make changes to their plans on an annual basis.3
Job-based health insurance open enrollment periods are set by your employer and can happen at any time of the year. However, it's most common for employers to have their open enrollment period in autumn so the new coverage begins on January 1 of the next year. But some employers choose to have a health plan year that doesn't align with the calendar year, so for example, you might find that your employer offers open enrollment in June, with a new plan year that starts in August.
Open enrollment in the individual market (on and off-exchange) runs from November 1 to December 15 in most states. This is the schedule followed by HealthCare.gov, which is the exchange platform that's used in 38 states as of 2020 (dropping to 36 for 2021, as Pennsylvania and New Jersey will be running their own exchange platforms).4 The District of Columbia and the other 12 states (14 in 2021) have more flexibility with their enrollment schedules, and most of them tend to offer longer enrollment windows. DC, Colorado, and California have permanently extended their enrollment windows, and a few other state-run exchanges have already announced extensions to the open enrollment period for 2021 individual market health plans.5 Note that Native Americans can enroll in individual market health plans through the exchange year-round, and are not limited to the annual open enrollment period.
Things to Know Before Choosing a Health Plan
Choosing a health insurance plan can be complicated. Knowing just a few things before you compare plans can make it simpler.
- The 4 “metal” categories: There are 4 categories of health insurance plans: Bronze, Silver, Gold, and Platinum. These categories show how you and your plan share costs. Plan categories have nothing to do with quality of care.
- Your total costs for health care: You pay a monthly bill to your insurance company (a “premium”), even if you don’t use medical services that month. You pay out-of-pocket costs, including a deductible, when you get care. It’s important to think about both kinds of costs when shopping for a plan.
- Plan and network types — HMO, PPO, POS, and EPO: Some plan types allow you to use almost any doctor or health care facility. Others limit your choices or charge you more if you use providers outside their network.
Types of Marketplace Plans
Some examples of plan types you’ll find in the Marketplace:
- Exclusive Provider Organization (EPO): A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).
- Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
- Point of Service (POS): A type of plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans require you to get a referral from your primary care doctor in order to see a specialist.
- Preferred Provider Organization (PPO): A type of health plan where you pay less if you use providers in the plan’s network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.
Sources: verywellhealth.com, healthcare.gov