Open Enrollment: What you need to know
At the end of each year, there is a period of time in which you can sign up for health insurance in which the health insurance company must insure you. Not all insurances take part in open enrollment or may have different periods of open enrollment. For example, Medicare open enrollment starts October 15th and closes the 7th of December every year.
Meanwhile, open enrollment periods for insurance based off of employment usually depends on your employer. For the individual market through the Affordable Care Act, this years’ open enrollment begins November 1st and ends December 15th. Most insurance policies established within this period will become effective January 1st of the next year.
Unless you qualify for special enrollment*, if you are unable to obtain insurance during the open enrollment period, you will most likely have to wait for the next enrollment period to obtain it.
Copayment/Copay: a specific dollar amount the patient must pay the provider for each encounter.
Example: You are responsible for paying $55.00 every time you visit a specialist.
Coinsurance: a “percentage copayment” meaning the patient is responsible for a fixed percentage of the total bill
Example: Your policy covers you at 80/20 meaning you are financially responsible for 20% of the cost of the service rendered.
Out-of-Pocket Expenses: the maximum amount of money the patient must pay for services in a calendar year; includes all medical and pharmaceutical expenses.
For example, if your OOP for a specific plan is $4000.00, once you spend a total of $4000.00, if you reach it, before the end of the calendar year, the rest of your services will be covered.
Deductible: specified amount of money that the insured must pay for covered medical expenses before the insurance policy begins to pay; usually an annual amount per individual or family.
Affordable Care Act (ACA): (also known as Obamacare or PPACA) Healthcare reform enacted in march of 2010 with the goals of making healthcare insurance available and affordable to more people, lower the costs of healthcare on a general scale and expand Medicaid (in some states) to cover all adults with income below 138% of the federal poverty level.
Premium: the cost of the insurance contract; the fee paid by the policyholder at regular intervals, usually monthly.
Explanation of Benefits (EOB): provides detailed payment information including date of service, services provided, amount charged and amounts paid by both the patient and insurance.
Special Enrollment: ability to enroll into insurances policies usually exclusively available during open enrollment at another time during the year. In order to get insurance this way, you must be experiencing a Qualifying Life Event (QLE). QLE’s are generally classified into four categories:
- Loss of health coverage
Example: Turning 26 years old and losing coverage through a parent’s plan
- Changes in household
Example: having a baby or adopting a child
- Changes in residence
Example: Moving to a different State
|Aetna PPO||No referral required|
|Aetna Meritan||No referral required|
|Allegiance/Orlando Health Network||No referral required|
|BCBS/ Florida Blue||HMO & PPO/EPO/Federal|
|Cigna||No referral required|
|Coresource Orlando Health||No referral required|
|Golden Rule||No referral required|
|Health Choice||No referral required|
|Humana HMO||PCP Referral Required|
|Humana PPO||No referral required|
|Humana Gold Plus||No referral required|
|Multiplan||No referral required|
|Tricare Prime||PCP Referral Required|
|Tricare Standard||No referral required|
|UMR||No referral required|
|UNITED HEALTH CARE COMERCIAL||No referral required|
|UNITED HEALTH CARE STUDENT||No referral required|
|All Savers United Health Care||No referral required|
INSURANCE THAT WE ARE NOT ACCEPTING:
- Allegiance Florida Hospital
- Ambetter Health
- Oscar Health Plan
- Cigna/ Florida Hospital
- Cigna/ Cigna Health and Life Insurance Company
- First Health
- Florida Health Care System
- Florida Health Plus