Navigating the annual Open Enrollment season. It’s a formidable task, and just when you’ve selected a plan that feels right for you, the season rolls around again and you’re once again plunged into the murky waters of HSA versus high-deductible, provider networks and qualifying life events.

For many people, the biggest challenge to selecting health coverage during the annual period for open enrollment is simply understanding the complicated terms that define it. In this post we’ll break down the most important terms you need to know in order to simplify the open enrollment process and choose the best health coverage for you and your family.

Agents (Health Insurance Agents) If your circumstances are unusually complicated or you have challenges which make it difficult for you to select health insurance coverage on your own during open enrollment, exchange navigators and licensed health insurance agents and brokers can help. The primary difference between the two is that health insurance navigators provide impartial education about the exchanges and exchange health plans. Their role is to help you determine your eligibility for subsidies or Medicaid, and to assist you with completing and submitting paperwork. Agents and brokers are more like personal shoppers who help you choose the right plan for you, and continue to assist you with tasks like filing claims or appeals even after you’ve selected a plan.

*infographic credit ehealthinsurance.com 

Catastrophic

This term applies to health plans that meet all of the requirements of other healthcare plans but they only cover 3 primary care visits per year before you’ve met your deductible. The monthly premium is generally lower than for other healthcare plans, but the out-of-pocket costs for deductibles, copayments, and coinsurance are generally higher. Essentially, you’ll pay little unless you have a major illness or injury – a “catastrophic” event that requires more care. To qualify for this type of plan, you must be under the age 30 OR get a "hardship exemption" - a determination that you cannot afford health coverage.

COBRA 

This term typically applies to those who’ve left or lost their jobs less so than to those selecting health coverage during the open enrollment period, but it’s still an important term to know.

Coinsurance This is the percentage of costs you’ll pay for medical care after you've paid your deductible. For example, if your allowed amount for an office visit is $100 and your coinsurance is 20% then:

• If you've paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest.
• If you haven't met your deductible: You pay the full allowed amount, $100.

Copay

Most of us know this one. This is the payment you’ll make to your medical provider in addition to what your insurance will pay for your services. This is the amount typically due from your pocket at the time of services.

Deductible

Another one most of us are familiar with, the deductible is the specified amount of money that you must pay before an insurance company will pay your claim. For example, if your deductible is $1,500, you'll pay 100 percent of eligible health care expenses until the bills total $1,500. After that, you share the cost with your plan by paying coinsurance.

EPO

An EPO is a type of managed care plan where services are covered only if you visit doctors, specialists, or hospitals within your plan’s network. That list is supplied to you when you are enrolled, but can be deferred in true emergencies.

Flexible Spending Accounts (FSA)

Also known as flexible spending arrangements, are arrangements between employers and employees allowing employees to pay for out-of-pocket medical expenses with tax-free funds set aside from their salary. Employees decide how much to place into their FSA, up to a limit set by the employer. 

HI Exchange

The Health Insurance Exchange is simply another term for the Health Insurance Marketplace®, a service available in every state that helps individuals, families, and small businesses shop for and enroll in affordable medical insurance. 

Healthcare.gov

Residents of most states will use this federal government website to enroll in their plan. However, some states such as California and New Jersey have their own website. Click here for a full list of links to state-run exchanges.

HMO

Similar to an EPO, this is a 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. Here’s how HMOs, EPOs, and PPOs differ.

Health savings account (HSA)

An HSA is a savings account that lets you set aside money from your paycheck pre-taxes to help you save/pay for qualified medical expenses so you can keep your premium payments down. They are often used by people with high-deductible health plans to pay for deductibles and copayments.

Major Medical

This is insurance intended to cover medical expenses resulting from severe or prolonged illness. This coverage pays all or most of the expenses above a set amount.

Medicare

Medicare is a health insurance program for people over the age of 65, certain eligible younger people with disabilities, and people with end-stage renal disease. Medicare is funded by the federal government amd does not appear on the Health Insurance Marketplace, but if you have Medicare, you are considered to have health coverage.

Metal Levels

Plans in the Marketplace are presented in 4 “metal” categories: Bronze, Silver, Gold, and Platinum. (“Catastrophic” plans are also available to those who qualify) Here’s how they differ.

Out of Pocket

These are any healthcare/medical expenses care that aren't covered/reimbursed by insurance

OEP Open Enrollment Period

This refers to the yearly period each autumn when you can enroll in a health insurance plan for the next calendar year. The Open Enrollment window for 2022 runs from November 1 through January 15, 2022. Be sure to enroll by December 15 in order to obtain coverage starting January 1.

Pre-existing conditions

This is any medical condition – for example, asthma or diabetes - that you have that affects your health and will be relevant to your selection of a new health care plan. It’s important to note that insurance companies cannot refuse to cover treatment for your pre-existing condition or charge you more for your policy.

Premium

This is the amount you’ll pay for your coverage each month.

Premium Tax Credit

This helps lower premium costs for those who cannot afford health coverage. Click the link to learn more about how to qualify, and how this credit can be applied.

POS (Point of Service)

With these plans you’ll pay less if you use doctors, hospitals, and other health care providers within your plan’s network. However, an important consideration with these plans is that you will also be required to obtain a referral from your primary care doctor in order to see a specialist, which may require additional office visits.

PPO (Preferred Provider Organization)

These plans are among the most popular types of health coverage. They allow you to visit any in-network physician or healthcare provider without a referral from your primary care physician.

Provider Network

Simply put, this is the list of the doctors, hospitals, and health care providers, and that your plan has contracted to provide your medical care. A provider that isn't contracted with the current plan is called an “out-of-network provider

QHP

This is a plan that’s certified by the Health Insurance Marketplace® to provide essential health benefits. It has limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements under the Affordable Care Act (ACA), also known as ObamaCare.

QLE

An acronym for Qualifying Life Event, this is a life change like getting married, having a baby, or losing health coverage that can make you eligible for a Special Enrollment Period, allowing you to enroll in health insurance outside the yearly Open Enrollment Period.

SPE (Special Enrollment Period)

Very similar to a QLE, this is a period of time outside the yearly Open Enrollment Period when you can sign up for health insurance. You qualify for a Special Enrollment Period if you’ve had certain life events Qualifying events include losing health coverage, moving, getting married, having a baby, or adopting a child.

Choosing a new plan for your family doesn’t have to be complicated. Read more about navigating open enrollment here.

Regardless of the insurance options you choose, ModRN Health can help you save up to 80% on your medications. Simply download the FREE app, search for your prescription drugs, and find the best prices locally, right now.

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