Understanding your health insurance options
With so many options to choose from, finding the right coverage isn’t always easy
At UW Medicine, we know you want health insurance that checks all the boxes. Ideally, it will cover planned and unplanned medical expenses with out-of-pocket costs you can afford. It will also let you see doctors (and use facilities) that provide excellent care.
When and how to change your health coverage
For most people with health insurance, you can make changes to your current plan (or switch to a new plan) during a specific time period once each year. This time period is called open enrollment.
The open enrollment period for most plans — including employer-sponsored, individual and government-sponsored plans — takes place during the months of October, November and December. For example, the annual open enrollment period for Medicare is Oct. 15 – Dec. 7.
In some instances, you can also make changes to your health insurance outside of the annual open enrollment period. You may qualify for this “special enrollment period” after a major life event, including:
- Changing jobs
- Getting married
- Giving birth or adopting a child
- Losing your job or your health insurance coverage
- Moving to a new state
- Turning 65
When it’s time to make changes (or change plans), thoroughly compare your options. Unless you have a qualifying life event during the next 12 months, you’ll be locked into your plan until the next open enrollment period.
What to look for when choosing a health plan
You may have an opportunity to enroll in one of several plans (defined below). For example, your employer may let you choose between HMO, PPO and high-deductible health plans. If you’re eligible for Medicare, your options include Medicare Parts A & B (Original Medicare) or a Medicare Advantage plan.
To help you understand the different types of coverage, we’ve provided definitions for some of the most common health insurance terms. Knowing what these terms mean can help you understand the out-of-pocket expenses for different health plans, which is helpful when choosing one plan over another.
First, it’s helpful to understand the differences between the most common plan types:
- Exclusive provider organization (EPO): This is a type of managed care plan, similar to a health maintenance organization. To be covered, enrolled patients are required to receive care from the doctors, specialists or hospitals in the plan’s network (except in an emergency).
- Health maintenance organization (HMO): This type of plan requires enrolled patients to receive most or all of their care from a specific group of providers (network). An HMO plan may also require your primary care provider (PCP) to make a referral before you can receive specialty care.
- High-deductible health plan: This type of plan usually has a higher annual deductible than other types of health insurance, with lower monthly premiums. A higher deductible means you’ll pay for 100% services up to a specific dollar amount before insurance coverage kicks in.
- Preferred provider organization (PPO): This type of plan gives you greater flexibility in managing your own healthcare. This plan lets you choose doctors and hospitals both in- and out-of-network. You may be able to see any specialist within the plan’s network of doctors without a referral from your PCP. You may also be able to receive treatment from a provider outside of the PPO network at a higher fee.
Next, it’s important to know how you and your insurance company may share costs:
- Annual deductible: This is the amount of money you’ll need to pay out of pocket for covered medical services before your insurance plan pays anything.
- Co-insurance: This is a fee you may need to pay for covered services after you meet your annual deductible. For example, if your plan pays for 70% of a covered service, you’ll need to pay the remaining 30%.
- Co-payment (co-pay): This is the fixed fee you pay for certain types of visits, at the time of service. You may have different co-pay amounts for primary care, specialist, urgent care or emergency room visits.
Finally, these are some features common to various health insurance plans. Familiarizing yourself with these terms can help you save money in the long run:
- Health savings account (HSA): This special savings account benefits people with high-deductible health plans. You can set aside pre-tax dollars to pay for certain medical expenses, including deductibles, co-pays and co-insurance.
- In-network: Each health insurance plan contracts with certain doctors, hospitals and other facilities to create a network. When you use one of these approved providers, it’s considered an in-network service.
- Noncovered services: This refers to any medical services not covered by your insurance company. If you receive noncovered services, you must pay for them out of pocket.
- Out-of-network: Any doctors, hospitals or other facilities that are not part of your health insurance company’s approved network are considered out-of-network. If you receive nonemergency care from an out-of-network provider, you may be responsible for paying some or all of the costs.
- Out-of-pocket maximum: The maximum dollar amount you’ll be required to pay out-of-pocket for covered services during a plan year. Once you reach your out-of-pocket maximum, your health insurance company pays for all covered services through the rest of the plan year.
Where to find coverage
Where you get your health insurance depends on several factors. These include your age, income level and whether you’re employed or retired.
In Washington, there are three main ways people obtain health insurance:
- Through your employer. Many small businesses and large companies provide health insurance to eligible employees. Your employer picks which insurance companies to partner with and which plans to offer.
- Through the health insurance marketplace. If you’re self-employed or can’t enroll in coverage through your employer, you can purchase “individual health insurance” from the state’s health benefit exchange (also known as Washington Healthplanfinder).
- Through the government. There are several types of government-funded insurance. These include free or low-cost Medicaid plans for people who meet specific income requirements (also known as Apple Health); Medicare coverage for people 65 and older (including Original Medicare, Medicare Advantage and Medigap plans); and coverage for active or retired military personnel (such as TRICARE).
No matter how you get your insurance, there’s a plan that includes UW Medicine.