Do you know what to look for when choosing a health insurance plan? Here are the things you need to know when enrolling in an employer-sponsored (you get your health plan through your employer) health insurance plan during Open Enrollment.
Know the basics
From deductibles to copays, what does it all mean? It's important to understand the basic language you’ll see when researching plans. This will help you understand what costs you’ll be responsible for and how much your plan will cost you monthly.
Some basic terms you’ll see when choosing a plan:
Premium: This amount is what you will pay monthly for health insurance.
Deductible: You will need to pay up to this amount for health services before your insurance begins to pay.
Copay: Each time you visit a health care provider or receive a service, you will pay this pre-determined amount for the service.
Coinsurance: You might pay a percentage of the cost of a procedure or service and your insurance pays the rest. Depending on your plan benefits, you may pay a coinsurance, plus any deductibles you owe.
Out-of-pocket maximum: This is the maximum amount you’ll pay for covered out-of-pocket costs each plan year. Once you reach this amount, your insurance will pay for any other covered care you receive.
Copays, deductibles and coinsurance are considered out-of-pocket costs.
Plans with higher premiums typically have lower out-of-pocket costs, which may be good for people with health conditions, children or those who see a physician or specialist frequently.
Plans with lower premiums typically have higher out-of-pocket costs, which may be a good fit for those who don’t need to see a doctor as often and want coverage for unplanned out-of-pocket costs, if they arise. Your health needs will often determine which health insurance plan is right for you.
Know your health insurance needs
Think about your current health and how you may have used your health insurance benefits in the past year. Were you diagnosed with a new condition? How many prescriptions are you currently taking? How many times in the past year did you visit your primary care provider or experience out-of-state travel? Do you have a dependent going to school out of state?
Health plans differ in cost, coverage and network so it’s important to choose a plan that fits your needs to get the most value from your health insurance.
See your benefits usage in myWellmark®
Log in to myWellmark to see how you’ve used your health benefits during the current and previous plan year. By seeing how much you spent on medical and pharmacy claims, you can feel confident with the level of coverage you choose for you and your family for the upcoming benefit year.
Know your health plan options
Now that you know what your needs are, it’s time to look at the types of plans you’ll see during Open Enrollment. These are the typical options you’ll see offered by your employer.
| Plan Type | Network | Cost share | This plan may be right for you if |
|---|---|---|---|
| HMO — health maintenance organization |
You can see providers within your plan’s specific network. Most MO network plans require you to designate a primary care provider. Out-of-network care is not covered, except for emergencies. While Wellmark doesn’t require a referral from your primary care provider to see a specialist, some specialists require it. |
These plans typically have lower monthly premiums. You may also see lower out-of-pocket costs when you see your designated primary care provider. |
You already have or want a strong relationship with your primary care provider and like having a clear network of care. |
| PPO — preferred provider organization |
You can see any provider you wish but will have lower costs if you visit in-network providers. While Wellmark doesn’t require a referral from your primary care provider to see a specialist, some specialists require it. |
Your monthly premiums will typically be slightly higher than if you choose an HMO or POS network plan, but you’ll have more in-network options for care. |
You want more flexibility in who you see, want to have a more hands-on approach to your health or travel out of state frequently. |
| POS — point of service plan |
Most POS network plans require you to designate an in-network primary care provider. You will likely pay a higher out-of-pocket amount for out-of-network care. While Wellmark doesn’t require a referral from your primary care provider to see a specialist, some specialists require it. |
These plans can have higher out-of-pocket costs, but you’ll have more flexibility in the providers you can see. |
You travel out of state or have a dependent living out of state. |
| HMO — HEALTH MAINTENANCE ORGANIZATION | |
|---|---|
| Network |
You can see providers within your plan’s specific network. Most MO network plans require you to designate a primary care provider. Out-of-network care is not covered, except for emergencies. While Wellmark doesn’t require a referral from your primary care provider to see a specialist, some specialists require it. |
| Cost share |
These plans typically have lower monthly premiums. You may also see lower out-of-pocket costs when you see your designated primary care provider. |
| This plan might be right for you if |
You already have or want a strong relationship with your primary care provider and like having a clear network of care. |
| PPO — PREFERRED PROVIDER ORGANIZATION | |
| Network |
You can see any provider you wish but will have lower costs if you visit in-network providers. While Wellmark doesn’t require a referral from your primary care provider to see a specialist, some specialists require it. |
| Cost share |
Your monthly premiums will typically be slightly higher than if you choose an HMO or POS network plan, but you’ll have more in-network options for care. |
| This plan might be right for you if |
You want more flexibility in who you see, want to have a more hands-on approach to your health or travel out of state frequently. |
| POS — POINT OF SERVICE PLAN | |
| Network |
Most POS network plans require you to designate an in-network primary care provider. You will likely pay a higher out-of-pocket amount for out-of-network care. While Wellmark doesn’t require a referral from your primary care provider to see a specialist, some specialists require it. |
| Cost share |
These plans can have higher out-of-pocket costs, but you’ll have more flexibility in the providers you can see. |
| This plan might be right for you if |
You travel out of state or have a dependent living out of state. |
Is an HDHP (high-deductible health plan) a good fit for me?
Another option you may have is a high-deductible health plan (HDHP), which has lower premiums in exchange for higher out-of-pocket costs when getting care. With an HDHP you may be eligible for a health savings account (HSA), which allows you to put money into an untaxed savings account to help pay for the higher out-of-pocket costs, if they arise.
An HDHP may be right for you if you have minimal health care needs and are able to make contributions to an HSA.
Know what else the health plans offer
Health and wellness discounts, virtual care, support programs and personalized member portals are just a few value-added benefits your health plan may offer.
Wellmark Blue Cross and Blue Shield health plans have several additional benefits to help you get the most from your health insurance plan:
- Blue365SM — exclusive health and wellness discounts for Blue Cross and Blue Shield members.
- myWellmark — a personalized member portal where members can access their benefits and claims anytime, anywhere.
- Doctor On Demand® — see a board-certified doctor using a tablet, smartphone or computer that can treat most common medical conditions or prescribe medication.
- BeWell 24/7 SM — a free 24/7 nurse line for Wellmark members.
A plan’s extra benefits add to the plan’s total value. It’s important to consider what extra benefits are included when deciding what plan is right for you.
Know when to choose
Your employer will let you know when it’s time for you to choose a plan, as enrollment periods vary by employer. The timeframe your employer designates as your enrollment period is typically the only time you can enroll in an employer-sponsored health plan. You can enroll in health coverage outside of Open Enrollment during a special enrollment period if you have a qualifying life event, like marriage or a loss of employment.
Have more questions about choosing a plan?
Purchasing an individual or family plan or considering Medicare coverage? Speak with a certified Wellmark agent Opens in a new window who knows health insurance inside and out and can help you find a plan that fits your needs and budget.
