Understanding Your Insurance Options During Open Enrollment

Open enrollment, as you may know, is a short window from the end of 2023 through the beginning of 2024. It allows patients to modify their insurance coverage to suit their needs according to their expectations for the upcoming year. While we can never be sure of our health status in the future, we likely have a good understanding of our health goals and have the opportunity to evaluate how medical and procedural options might fit into them. With this analysis and knowledge, we can approximate our medical insurance needs for the next year and choose a plan.

How exactly do we do that? And what plan might be best? If your plan is part of the insurance marketplace, you will have several options, from PPO to HMO and bronze to platinum. Understanding these options can help you best choose a plan.

Different Metal Colors

Typically, the lower the metal color, the lower the premium, and the higher the out-of-pocket expenses above and beyond the premium. With weight loss surgery, knowing if the procedure may be covered while calculating how much you will be spending out of pocket – think deductibles, co-insurance, co-pays, and total out-of-pocket expenses is essential. While your specific plan will ultimately determine these amounts, you can get advice online on what metal makes the most sense.

HMO vs. PPO

Similarly, choosing between an HMO and a PPO is a big decision. The HMO costs may be somewhat lower, but you are limited in the providers you can see. Anyone outside of the HMO’s network would not be covered. You’d also need a referral to see a specialist. On the other hand, PPOs typically have a wider net of in-network providers but also provide coverage for out-of-network care, albeit with different deductibles and out-of-pocket expenses.

If you were considering cash-pay bariatric surgery, the all-in special gastric sleeve pricing many surgeons offer may be compelling, especially compared to the ever-rising cost associated with medical premiums and the ever-higher deductibles and out-of-pocket maximums. Ultimately, the decision on which plan and what provider to choose is a highly personal decision you must make each year.

What You Need to Know

Co-pay: The amount you must pay at each office or surgery center visit. This is usually a fixed amount that does not go toward your deductible but does count toward your maximum out-of-pocket expense.

Deductible: the amount you must pay before insurance benefits kick in for payment. You still receive the insurance contracted rate with your provider or facility.

Coinsurance: the amount, usually expressed as a percentage, that you must pay after reaching your deductible. This will apply until you reach your maximum out-of-pocket expense for the year.

Maximum out-of-pocket: this is the most you will have to pay for medical care for the calendar year.

Most importantly, don’t ignore open enrollment; this is a time to reestablish your healthcare coverage and ensure that your expenses match your needs. We wish you a happy and healthy 2024.