Our Healthcare System Sucks: Breathing & Getting Ready for Open Enrollment

Introduction

Hey there, friends! The 2023 Open Enrollment Period begins November 1, 2022, so we thought we’d take a minute to break down some of the things you might want to consider when navigating your healthcare choices for the upcoming year. 

First things first:

Yeah, this system absolutely sucks. It is confusing and complicated and daunting, and can leave you feeling like less of a human being in the midst of trying to navigate it. This system sucks. But you still deserve to get care and to be informed, so it’s crucial to have as much information under your belt as possible, yeah? 

What are we talking about when we say the Open Enrollment Period? (Great question!) Open Enrollment pertains to folks who will be going through HealthCare.gov to secure their insurance for the following year. The Health Insurance Marketplace is for people who do not already “have health insurance through a job, Medicare, Medicaid, the Children's Health Insurance Program (CHIP), or another source that provides qualifying health coverage.”

The Open Enrollment Period is “the yearly period in the fall when people can enroll in a health insurance plan for the next calendar year.” Now, there are certain factors – losing other health coverage, having a baby, etc. – that might qualify a person for the Special Enrollment Period later in the year, but the vast majority of us are going to want to be prepared when November 1 rolls around.

So, I have to do the whole thing and make my decision on November 1?

Another great question!

Open Enrollment for 2023 runs from November 1, 2022 to January 15, 2023, so you do have some time. (And, if you’re like me and have enrolled through the marketplace before, get ready for all the email reminders ever.) There are some benefits to getting in there early, though; if you enroll by December 15, that will help you guarantee your coverage begins on January 1, 2023. These dates can vary by state, so it’s important as we get into the season for everyone to check their specific timeline!

Already feeling overwhelmed? Yep, us too! Take a deep breath, take a break if you need one, but then come back. We’ve got more to talk about, friend.

(Oh, also: do you prefer videos over articles? The very funny and brilliant Brian David Gilbert JUST came out with a super clear (and entertaining) 30 minute video about understanding healthcare terminology. Check it out here!)

Important Vocabulary

Navigating healthcare is absolutely stressful if you don’t know what all the terms mean. And no judgment! We all had to learn sometime. If you need a refresher on some of the most important terms related to healthcare, here’s a quick glossary, courtesy of the folks at HealthCare.gov:

Premium: The amount you pay for your health insurance every month. (Your premium is a flat fee, and not something that varies depending on monthly usage.)

Deductible: The amount you pay for covered health care services out of pocket before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.

Co-pay: A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible. Copayments (sometimes called "copays") can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.

Allowed amount: The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.” If your provider charges more than the plan’s allowed amount, you may have to pay the difference. 

Co-insurance: The percentage of costs of a covered health care service you pay after you've paid your deductible. For example, if you have co-insurance of 20% and you have a $1000 procedure that happens after your deductible, you’d pay 20% of this, or $200, and your insurance provider would cover the remaining 80%, or $800.

Excluded services: Health care services that your health insurance or plan doesn’t pay for or cover.

In-network: (For this definition, we’re borrowing some handy language from NerdWallet.) ‘“In-network” health care providers have contracted with your insurance company to accept certain negotiated (i.e., discounted) rates. Say you go to a doctor that's in-network and the total charge is $250. A discount is applied to that amount for our negotiated rate with the doctor. The discount is $75. Blue Cross Blue Shield of Michigan pays $140. You'll have to pay the remainder, which is $35.’

Out-of-network: Following the previous example, “Now let's say you go to a doctor that's out-of-network. No discount is applied to the total charge. We still pay $140 but you'll be responsible for the remainder, which is $110.”

Max out-of-pocket: The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.

High deductible health plan: A plan with a higher deductible than a traditional insurance plan. The monthly premium is usually lower, but you pay more health care costs yourself before the insurance company starts to pay its share (your deductible). 

If you’re scratching your head at all, there are often examples of these terms alongside the definition over at HealthCare.gov. Here’s another really handy glossary chart that includes a great example of how you and your insurer share costs. 

Things to Think About

Before Open Enrollment gets going, we recommend you calculate what makes the most financial sense for you when choosing a plan. I know in the past I have definitely been that person who panicked about an extra monthly cost of any kind, and therefore I simply picked the cheapest Bronze plan available. But then I had a hard time that year finding providers within my network who were actually accessible to me location-wise; I used exclusively public transit at the time, so if I couldn’t find a doctor on the train or bus line, I was out of luck! It’s important to remember that the all-in cost of healthcare isn’t just the cost of the premium; it’s also all the other things you pay for, plus the cost of your valuable time and energy. 

There are a few helpful tools out there to help you figure this out for yourself. For starters, here’s a handy calculator where you can enter factors such as income and family size in order to see what the average person like you actually spends on healthcare within a year. To be clear, this is really just for reference, and doesn’t include any actual personal data. But it might make you feel better about the fact this is all just flat out expensive.

Now, that’s a lot of numbers to think about, so what’s helpful for those of us who are more word or narrative based? I really appreciated this article from Business Insider’s Zachary Tracer about how he determined his employers’ free plan wasn’t actually the best option for him. One helpful tip in the article is, “If you don’t have access to a health-policy researcher to run this analysis, one quick trick is to add up your total annual premium and the maximum out-of-pocket limit of your insurance choices. That’ll give you a quick sense for how much you could wind up paying, in total, if something really bad happens.” Tracer’s specific situation might not apply to you, but it’s a good example of why it’s worth it to really sit down and do the math, comb through old statements, etc. 

Picking a healthcare plan for the entire year can be a daunting proposition. We hope you’ll fix yourself your favorite fall-themed beverage while you go through some of these resources, and take the time to make sure you’re really setting yourself up for success. At the end of the day, if you still don’t feel confident to go through this process alone, you might want to consider working with a broker. An agent or broker is “A trained insurance professional who can help you enroll in a health insurance plan.” You will likely have to pay a broker for their services, but you will likely be saving on money (and time) overall by getting help from a professional. 

Again, if you’re like me and you want to stop thinking about healthcare as soon as possible, you might be tempted to just try to enroll in the same plan you had last year. But we grow and we change, and so do our medical needs. Take the time to think about what 2023 is going to look like for you and your family. Are you planning any major procedures, surgeries, or care regimens? Are you or a family member planning for a pregnancy or gender affirming surgery? If you have big medical expenses coming up, it is often worth springing for a higher tier of service. 

That’s the biggest piece of advice I have in this article: Take the time. As we said up top, this system sucks, and it can be painful to navigate. Start thinking about what you need now, so that you’re ready to go on November 1. (Though, again, you have time.) When things get hard or confusing, take a break, walk away. But come back. Don’t devalue your own health out of frustration for the system.