How to Compare Health Plans During Open Enrollment

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When comparing health plans during open enrollment, people often look at the monthly premium first. While it’s an important part of the decision, it doesn’t tell you what your healthcare may actually cost over the year.

For example, imagine you’re comparing two health plans. One has a lower monthly premium but a higher deductible. The other plan costs more each month but has a lower deductible and different copays or coinsurance.

If you rarely need medical care, the lower-premium plan may be appealing. But if you regularly visit specialists, take prescription medications, or expect ongoing treatment, the higher-premium plan could potentially cost less overall.

Start by calculating the annual premium for each plan. Then consider what you might pay for regular appointments, prescriptions, and other services. Remember, meeting your deductible doesn’t necessarily mean you’re done paying. Copays and coinsurance may continue until you reach your out-of-pocket maximum.

One thing worth double-checking is the provider network. Even when the same insurance company offers two plans, their networks may differ. If keeping a particular doctor, specialist, hospital, or medical group is important to you, verify that the plan you’re considering includes them.

Prescription coverage can also make a difference. A medication covered under one plan may have different costs or coverage requirements under another. Checking your prescriptions before enrolling can help you avoid surprises.

The goal isn’t necessarily to find the plan with the lowest premium or deductible. Choose coverage that fits your healthcare needs and budget. Before making your final decision, review each plan’s Summary of Benefits and Coverage (SBC). It provides a standardized overview of covered services and cost-sharing, making plans easier to compare.

 

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Understanding Your Deductible and Out-of-Pocket Maximum

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Your deductible and out-of-pocket maximum are two important numbers to understand when using your health plan, but it’s easy to confuse what each means.

Your deductible is the amount you generally pay for covered healthcare services before your health plan begins sharing the cost. Depending on your plan, some services may be covered before you meet the deductible, while others may require you to meet all or part of it first.

Your out-of-pocket maximum works differently. It is the most you may have to pay during the plan year for covered, in-network healthcare services that count toward the limit. Once you reach that amount, your health plan generally pays 100% of covered, in-network services for the remainder of the plan year.

Remember, reaching your deductible does not mean you are finished paying for healthcare. After meeting the deductible, you may still have copays or coinsurance until you reach your out-of-pocket maximum.

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What to Know Before Open Enrollment Begins

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Open enrollment is approaching, and for many people the process will look familiar: review the available plans, look at the monthly premiums, and decide whether to keep the same coverage for another year.

But the plan with the lowest premium isn’t necessarily the plan that will cost you the least, and the plan you have today may not be the best fit for you next year.

Before open enrollment begins, take some time to look at how you actually used your healthcare this year. Your claims, prescriptions, provider visits, and out-of-pocket expenses can tell you a lot about what to focus on when comparing plans.

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July is UV Safety Awareness Month

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Summer is a great time to enjoy longer days and spend more time outdoors. It is also a good time to think about protecting your skin from ultraviolet (UV) rays.

UV rays cause sunburns, premature aging, and an increased risk of skin cancer. While a sunburn may fade after a few days, repeated exposure to UV rays can have lasting effects on your skin.

The good news is that a few simple habits can make a difference:

  • Choose a broad-spectrum sunscreen with an SPF of 30 or higher and reapply every two hours, or more often if swimming or sweating.
  • Wide-brimmed hats, sunglasses with UV protection, and lightweight long sleeves can help reduce sun exposure.
  • The sun’s rays are typically strongest between 10:00 a.m. and 4:00 p.m., so try to limit sun exposure during these hours.
  • UV rays can pass through clouds, so sun protection is important even when it is overcast outside.
  • Become familiar with your skin and talk with your healthcare provider if you notice a new or changing mole, spot, or lesion.

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Why Prior Authorization Matters

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Your healthcare provider recommends a medical test or procedure, but before you can schedule it, your health plan may require one more step: prior authorization.

Prior authorization is a process some health insurance plans use to determine whether certain medications, imaging tests, procedures, or medical services meet the plan’s coverage requirements before they are provided. While not every service requires prior authorization, many plans use it for higher-cost services or treatments.

The purpose of prior authorization is to help ensure that care is medically appropriate and consistent with a health plan’s guidelines. Requirements vary by insurance carrier and health plan, which means a service that requires prior authorization under one plan may not require it under another.

One common misconception is that if a healthcare provider recommends a service, it is automatically covered by insurance. Provider recommendations and insurance coverage decisions are separate. Even experienced healthcare providers may not know the specific requirements of every health plan.

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Why Healthcare Costs Can Vary So Much for the Same Service

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Many people are surprised to learn that the cost of healthcare services can vary significantly, even when the service itself appears to be exactly the same.

For example, two individuals may receive the same imaging test, lab work, or office visit and receive very different bills depending on where the service was performed, whether the provider was in-network, and how their health plan is structured.

One of the biggest factors affecting cost is provider networks. In-network providers have negotiated contracted rates with insurance carriers, which are generally lower than out-of-network pricing. Out-of-network care may result in higher deductibles, coinsurance percentages, or additional balance billing depending on the plan.

Health plan design also plays a major role in what someone pays out of pocket. Traditional PPO plans often include fixed copays for services such as office visits or prescriptions, which can make costs feel more predictable. HSA-compatible high-deductible health plans typically operate differently. In many cases, individuals enrolled in HSA plans may pay the full contracted cost of services until the deductible is met, after which coinsurance may apply.

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IRS Announces 2027 HSA Contribution Limits

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The IRS released the contribution limits for Health Savings Accounts (HSAs) for 2027. In the upcoming year, we will see an HSA contribution limit increase to $4,500 for individuals and an increase to $9,000 for a family. The IRS implemented inflation-adjusted parameters for health savings accounts in Revenue Procedure 2026-24.

For 2027, individuals with self-only coverage can contribute up to $4,500 to their HSAs, up from $4,400 in 2026. Individuals enrolled in family coverage can contribute up to $9,000, up from $8,750 in 2026. The IRS also noted that the 2027 catch-up contribution for those aged 55 and older will remain $1,000, unchanged from 2026.

Health Savings Accounts remain a valuable tool for individuals and families enrolled in qualified high-deductible health plans (HDHPs). HSAs offer tax advantages, allow unused funds to roll over from year to year, and can serve as a long-term savings vehicle for future healthcare needs.

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Understanding Copays vs. Coinsurance

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Many people have heard the terms copay and coinsurance, but understanding the difference between the two can help make healthcare costs more predictable and easier to understand.

A copay is usually a fixed dollar amount paid for a specific service, such as a primary care visit, specialist appointment, or prescription. For example, you may pay a $30 copay for an office visit regardless of the total cost of the appointment.

Coinsurance works differently. Instead of paying a fixed amount, coinsurance is a percentage of the cost of a service that you are responsible for paying after meeting your deductible. For example, if your plan has a 20 percent coinsurance, you may pay 20 percent of the allowed cost for a covered service while your health plan pays the remaining amount. Out-of-network care may also result in higher out-of-pocket costs, as coinsurance percentages and allowed amounts can differ from those for in-network services.

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Why More People Are Using Telehealth

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Telehealth usage continues to grow as more individuals look for convenient and accessible healthcare options. While virtual care existed before COVID-19, the pandemic significantly accelerated its adoption as healthcare providers and patients looked for safe ways to access care remotely.

Telehealth visits have continued to increase in recent years, and many patients value the convenience and flexibility that virtual care provides. Telehealth is commonly used for primary care visits, behavioral health support, prescription refills, follow-up appointments, and other non-emergency concerns.

For many people, virtual visits reduce travel time and make it easier to fit appointments into busy schedules. A good example of when telehealth may be useful is for concerns such as conjunctivitis (pink eye), where an individual may receive care quickly without an in-person visit and have medication prescribed if necessary.

Many health plans now include telehealth services as part of their benefits, and virtual care can often be a lower-cost option than urgent care or emergency room visits for non-emergency conditions. CalCPA Health medical members have access to LiveHealth Online for virtual medical and behavioral health visits.

Individuals should check with their healthcare providers to see if telehealth options are available. It can also be helpful to review plan documents to understand how telehealth services are covered under a specific health plan, including costs and eligible services.

Understanding when telehealth is appropriate can help individuals make more informed decisions about where to receive care and may provide a convenient option for accessing healthcare when in-person visits are not necessary.

While telehealth can be helpful for many non-emergency concerns, individuals experiencing severe symptoms or medical emergencies should seek in-person or emergency care when appropriate.

Coverage and telehealth services may vary by plan and provider. Members should review their plan documents and confirm coverage details before receiving services.

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