Open enrollment for health insurance through work

Understanding coverage when you're choosing a plan offered by your employer

Open enrollment is your time to choose your health insurance plan for the year. If you're choosing a health insurance plan offered by your employer, it's important to think about the kind of coverage you’ll need for the year ahead. Then you can make a decision that may work best for your life situation.

Your employer may offer more than one plan for you to consider. As you compare your options, consider what might work best for your budget and your care needs. Let's go over some coverage details that may be helpful to know as you make your decision. 

Plans cover network care providers differently

Each health insurance plan has agreed to cover care through a network of designated doctors, specialists, and facilities. Some plans only help cover care within its own network. Other plans are more flexible and agree to cover a part of the cost for out-of-network providers. It's important to learn if your provider is in the network for the plan you're considering. You can also check to see if there is partial coverage for out-of-network providers. 

Plans cover preventive and diagnostic care differently

The care you receive is considered either preventive or diagnostic. Each health plan covers these differently. Let's go over what each one means. 

What is preventive care?

Preventive care helps you stay healthier — before you have symptoms. Plans often cover these types of preventive care:
  • Routine checkups, immunizations and tests.
  • One wellness visit per year. Check each plan’s covered preventive services and find out how often you can use preventive services in one plan year.

What is diagnostic care?

Diagnostic care helps you determine what's wrong — when you already have symptoms. Plan coverage can vary and you may have to pay more for diagnostic care services like these:
  • Services other than routine care 
  • Certain tests, procedures, doctors and specialists. Ask which of these are considered diagnostic before you receive care. These services generally cost a lot more.

Check your options before you get care to learn if there are cost-saving ways to get care for minor care needs or injuries. 

How can I tell if the care I need is preventive or diagnostic?

Since coverage can change depending on whether care is considered preventive or diagnostic, it's important to understand the difference. Here are a few examples to help explain how it works. 

Type of visit  Preventive care Diagnostic care
Primary care visit If you visit your doctor for a wellness checkup.  If you visit your doctor because you have a cough that isn't getting better.
Mammogram  If you have a routine mammogram to screen for breast cancer. If your doctor orders a mammogram to learn more about a lump that was found. 
Colonoscopy If you have a routine colonoscopy but do not have symptoms. If your doctor orders a colonoscopy based on symptoms you're having. 

Review plan documents to understand coverage details

You can find more coverage details by reviewing these health plan documents before you enroll in a plan:

  • Summary of benefits: Read this document to get an overview of coverage for each plan, including benefits, cost-sharing requirements and coverage limitations and exceptions. 
  • Plan coverage document: Ask your employer for this document that will offer a deeper dive into the coverage details for each plan.

Remember, it's good to ask questions so you understand the coverage details of each plan before you enroll. 

Choosing your health insurance plan

Knowing the coverage your plan may offer is a good place to start. Next consider your own personal situation. We all have different coverage needs. Before you enroll in a plan, think about the care you or your family may need and if your plan will help cover those costs.

Disclaimers

Certain preventive care items and services, including immunizations, are provided as specified by applicable law, including the Patient Protection and Affordable Care Act (ACA), with no cost-sharing to you. These services may be based on your age and other health factors. Other routine services may be covered under your plan, and some plans may require copayments, coinsurance or deductibles for these benefits. Always review your benefit plan documents to determine your specific coverage details.