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It's Time for Open Enrollment for Health Insurance for 2016-2017!

It’s time for open enrollment. What does that mean? by Carol Kuter, Office Manager

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For many of us, it’s time to choose our health insurance coverage for next year. With open enrollment meetings around the corner, you will probably hear a few terms that may be unfamiliar. Below is a list of some common terms that may be helpful.


ACA: Affordable Care Act: also referred to as Obamacare. Passed in 2010 by President Obama in hopes of lowering cost and offering coverage to people that are uninsured.

Allowed amount: This is the maximum amount your physician has agreed to accept as payment for services rendered. So if the normal charge is $125 for an office visit, your insurance company has negotiated a discounted rate.

COBRA: Consolidated Omnibus Budget Reconciliation Act of 1985. Federal Act allowing employees to continue health insurance coverage after termination of employment, child aging out, death, divorce, or reduced work hours. Generally paid by the employee.

Copay: A set amount the patient is responsible for paying for services rendered instead of a deductible.

Covered service: Medical services that are covered by the plan. Not all services are covered. It’s a good idea to become familiar with what your plan covers

Deductible: The amount you’re responsible for paying before the insurance plan will reimburse. Generally, if you have a high deductible, your monthly premium should be less.

Dependent: Someone covered on the plan in addition to the insured, usually a child or spouse.

Drug formulary: A list of preferred drugs chosen by the insurance company that they will cover. We are seeing less and less being covered each year. If you take medicines routinely, ask your health insurance company for their list.

Effective Date: The date your coverage starts.

EOB: Explanation of Benefits. Once your claim has been processed the insurance company will issue an EOB showing what is covered, payment (if any) made, denials, and what is owed by the patient.

Exclusions: medical conditions that are not covered by the insurance.

Grandfathered health plan: An insurance plan that was effective prior to ACA. This allows employers to keep the same plan benefits and they are not required to follow the ACA guidelines.

Guaranteed issue: Under the ACA, health insurance plans cannot exclude you due to age, gender, or other issues.

The Marketplace: The Health Insurance Marketplace or Health Insurance Exchange. Started by the ACA where you can shop and buy health insurance.

PPO: Preferred Provider Organization: An insurance plan that has contracted with a group of physicians and hospitals at a discounted rate.

HMO: Health Maintenance Organization is similar to a PPO but has stricter guidelines regarding benefits and what is paid. Generally, the patient is required to see their primary care physician (PCP) first before seeing a specialist. The idea is to control cost by seeing a PCP first.

PCP: Primary Care Physician: Pediatricians, Family Practice, Internal Medicine or OB/Gyn. Co-ordinates care with specialist. Some plans require you to choose a PCP.

Network: group of doctors and hospitals that your insurance plan has contracted with for your PPO or HMO coverage.

Out of network: Doctors that are not contracted with your PPO or HMO.  Services would not be covered at the same level as “in-network.”

Out of pocket expense: Any expense your insurance company does not pay, including copays, deductibles, co-insurance, prescriptions, and non-covered services.

Minimum Essential Coverage (MEC): minimum amount of coverage to meet the requirements of the ACA.

Open enrollment: time period, usually once a year, where you can choose or change insurance coverage.

Qualifying Event: An event that allows you to add, change or enroll in coverage outside the open enrollment period. This can be marriage, divorce, birth, adoption, or death in the family.

Preexisting: A condition or illness that you had prior to your health insurance coverage. Some plans may not cover a pre-existing condition. Although, we rarely see this with the ACA.

Insurance can be confusing. If you have questions, our billing office may be able to help.


For a list of plans we participate in, click here.