Healthshare vs. Major Medical: A Clearwater Guide to Navigating Open Enrollment
It’s open enrollment season for 2023! OK, now what? If you’re wondering what that means and why open enrollment is important to you, don’t worry. You’re not alone. Choosing a healthcare plan for you and your family can be a bit intimidating—especially if you’re under an end-of-year time deadline to get it done.
Your healthcare choice involves key considerations—specific care needs for you and your family, and your budget, for starters. Plus there’s a lot of confusing language and terminology in the healthcare space: copays, deductibles, PPOs, HSAs. The list goes on.
But open enrollment doesn’t have to be an overwhelming process. To help cut through the noise and set you up for healthcare planning success, we’ve created this handy guide to navigating open enrollment 2023. It includes definitions, timelines and Clearwater Benefits health plan options to consider. With us, you’re not always tied to the stricter rules and timeframes of the Affordable Care Act (ACA) exchanges. Clearwater offers a broad range of flexible options to meet your health and financial needs.
When you understand your options, you can make open enrollment decisions with confidence and ease.
A Clearwater Guide to Navigating Open Enrollment
What is Open Enrollment?
Open enrollment is the annual time of year for individuals who don’t get health coverage through their workplace to enroll themselves in a new health plan, or make changes to current coverage. It’s the time to review your current plan, and assess how it’s working for you and your family.
When Do I Have to Act?
It varies. For most states, the 2023 window for open enrollment on the Marketplace (also known as the ACA exchanges , Healthcare.gov, or Obamacare) opened on November 1, 2022 and runs through December 31, 2022. There are a few key timing factors to know:
- If you want your Marketplace health plan to start on January 1, 2023, you need to enroll by December 15, 2022
- If you don’t act by December 31, 2022, you can’t get coverage for 2023 through the ACA exchanges unless you have a qualifying event, like getting married, having a baby, or getting legally separated or divorced
Note that the end of year deadline is for enrolling in Marketplace plans. With Clearwater, however, you have more flexibility.
Clearwater offers healthshare memberships that you can enroll in year-round. In other words, with Clearwater you don’t need to enroll in a healthshare plan during open enrollment. In fact, you can even backdate your coverage: if you enroll by January 15th, for example, you can backdate your coverage to January 1.
If you’d rather enroll in a more traditional insurance plan, Clearwater also offers Major Medical plans. The deadline to enroll in Clearwater’s Major Medical plan for 2023 coverage is December 31, 2022. Otherwise there’s a 60-day waiting period for your coverage to begin.
What is a Healthshare Plan?
A healthshare, or a healthcare sharing ministry, is not insurance. It’s a community where you share eligible healthcare expenses with other members. Healthshares help cover their member’s medical needs and can reduce monthly costs and out-of-pocket expenses. They make a great option for families and individuals alike.
With a healthshare, you can get access to high-quality medical care when you need it, while protecting yourself financially. Healthshares often require members to handle a little bit more administrative work than many people are used to, and age and health condition limitations can apply. These limitations help keep costs low for the whole community.
What is a Major Medical Plan?
Major medical plans are traditional insurance plans that have no limitations. They often come in four health plan categories, named after metals: Bronze, Silver, Gold and Platinum.
The less valuable the “metal”, the lower your monthly premium, but the more you’ll have to pay when you need care.
For example, with a bronze plan you’ll likely pay less each month, but you’ll have to pay 40% of your bill if you need a major procedure. With a platinum plan, you’ll pay more each month, but you’ll only have to pay 10% of your bill if you need a major procedure.
What Types of Plans Does Clearwater Offer?
Clearwater offers five major medical plans and four healthshare plans. For major medical, you can choose from three copay plans, one Health Savings Account (HSA) plan, and one Minimum Value Plan (MVP). Or opt for one of Clearwater’s Clearshare Healthshare plans: Advanced, Basic, Clearshare and HSA.
What is Included in Plans from Clearwater?
The healthshare and major medical plans we offer include the following:
- $0 telemedicine
- Mental health coverage through our partnership with Talkspace
- A care coordination service that can completely waive your out-of-pocket costs
- Broad access to large, nationwide PPO networks, with providers from coast to coast
- Low cost prescriptions, including $0 generics and patient prescription programs to help with high-cost Rx
What is a Healthcare Network?
A healthcare network is a group of doctors, hospitals, and medical service suppliers and providers that work with your chosen plan type. Most people are on an HMO or a PPO network.
- An HMO is a Health Maintenance Organization. With an HMO plan, your coverage only applies to providers in your network. Out-of-network providers aren’t covered at all. If you need to see a specialist, you might need to get a referral from a primary care provider.
- A PPO, or Preferred Provider Network, is a broader network of care providers that you can visit without a referral. They often offer a broader geographic range of services than an HMO.
HMO’s typically have lower monthly premiums, but less flexibility. They can be more budget-friendly, but have a limited range of services. PPO’s usually cost more but provide a wider range of care options within your plan.
How Do Monthly Premiums and Deductibles Work?
Health plans are made up of two primary, interconnected cost components: The monthly premium, and the deductible. In most cases, the higher the monthly payment, the lower your deductible, and vice-versa.
- Your monthly premium is the fixed amount of money that you have to pay each month for your health coverage. This sum depends on factors including the type of plan you choose, the number of family members on your plan (and their ages), your location and more.
- Your deductible is the amount of money that you have to pay for health care services each year before your plan starts to cover the costs. For example, if you’re on a plan with a $1,000 deductible, you would have to pay the first $1,000 for covered services yourself before your plan kicks in to cover the costs.
Worth noting, monthly premiums and copays typically don’t count toward your deductible. Neither do elective services that are out of your coverage plan (some cosmetic surgeries, for example), or out-of-network care.
What's a Copay?
A copay is a fixed fee you have to pay for a covered health care service, after you’ve paid your deductible. For example, you might have to pay $35 to cover a visit to your primary care doctor, and then your insurance will pay for the rest of the visit.
What is the Maximum Out-of-Pocket Annual Limit?
This one’s tricky. The maximum out-of-pocket limit is the highest amount of money you’d have to pay yourself on covered health care services during the plan year. It’s set by the federal government and changes annually.
For the 2023 plan year, the maximum out-of-pocket limits for plans on the marketplace are $9,100 for an individual and $18,200 for a family.
Note that things like out-of-network care, monthly premiums, and care services not covered by your plan don’t count toward your limit.
That's a Lot! How Do I Navigate Open Enrollment Successfully?
When you’re considering making changes to your health care during open enrollment, gather the following information:
- The name of your current health insurance company, or carrier, such as United Health, Anthem or Humana.
- Your current plan name, which usually includes your network type (e.g. HMO, PPO,), your plan category (bronze, silver, gold or platinum), and your annual deductible. Your plan name may look something like “HMO Silver 5000” or “PPO Platinum 1000.”
And think through your financial considerations.
- Consider your monthly premium. Do you want a lower monthly payment? If so, you’ll have to pay more out-of-pocket for specific health services.
- Do you want to control your out-of-pocket expenses the most? Check your deductible. The lower this is, the more you’ll pay each month.
- Think about your lifestyle and potential care needs for the coming year. Do you have any procedures planned? Will you be going to the doctor more for any reason?
Thinking through questions like these can go a long way toward helping you make your health care plan choice with confidence.
Who Can I Talk to for More Information?
If you’d like to learn more, you can easily book a presentation with one of our care agents or quickly get an online quote for any of our Major Medical insurance and Healthshare plans.
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