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Medicare Open Enrollment FAQs


The ins and outs of health insurance can be complicated and confusing – even for people who work in healthcare!

Medicare’s open enrollment period began October 15. As you prepare to make a decision about which healthcare plan is right for you, we want you to make sure you know exactly what to look for when comparing plans, what questions to ask and what resources to turn to when you need guidance.

What is Medicare open enrollment?

Medicare open enrollment, or annual election period, began October 15 and ends December 7. During this time, enrollees can make changes to their coverage plans or purchase new policies. Changes that can be made during open enrollment include:

  • Making a switch from Original Medicare to Medicare Advantage (some restrictions apply)
  • Making a switch from Medicare Advantage to Original Medicare
  • Making a switch between Medicare Advantage plans
  • Making a switch between prescription drug plans
  • Enrolling in a new prescription drug plan

What is a healthcare premium?

Your premium is your baseline cost for health insurance to keep your policy active. Even if you have zero healthcare claims, you will still pay your premium cost. Typically, a higher upfront premium cost equates to a lower deductible.

What is a deductible?

Your deductible is the amount you pay out-of-pocket for claims until your plan benefits begin. You must pay all of your deductible before your co-insurance begins to kick in.

What is co-insurance?

Co-insurance is the percentage you are responsible to pay after you meet your deductible. If your co-insurance is 20%, after you meet your deductible, you will be responsible for 20% of the remaining cost while your health insurance plan will cover the other 80%.

What is a co-pay?

Co-pays are flat fees that are pre-determined for certain types of services. Co-pays may or may not count toward your deductible – this is something that is specific to your plan.

What is an out-of-pocket (OOP) maximum?

Your out-of-pocket maximum is basically what it sounds like – the maximum amount of money you will pay during your plan’s coverage period before your plan pays your claims at 100% (not including your premium fees). Co-pays and co-insurance payments typically count toward your OOP max, but premiums do not. Note that not all plans have an OOP max.

What is a provider network? What do I need to know about networks when choosing my plan?

Health insurance plans have agreements with networks of healthcare providers and facilities (like doctor’s offices, hospitals and urgent care centers) for billing purposes. Choosing providers and facilities within your plan’s network will typically result in the lowest cost for you.

Some plans will not cover any care received by out-of-network providers or at out-of-network facilities, while some plans will cover – but at a lower rate. For example, if your in-network co-insurance is 20% (meaning the plan pays 80% after you meet your deductible), your out-of-network co-insurance may be 40% (meaning the plan will only pay 60% after you meet your deductible).

When choosing a plan, it’s important to make sure that your preferred providers and facilities are within the plan’s network – or to make sure that you are comfortable with finding a new provider who is in network and understanding that you may have to travel to a hospital outside of the local area to receive in-network services.

Now what? How do I choose a plan?

When comparing your options and choosing a plan, make sure you ask and understand the answers to these questions:

  • Is your primary care provider in-network?
  • If not, are you comfortable finding a new provider who is in-network?
  • Is your closest or preferred hospital in-network?
  • If not, are you comfortable traveling to the nearest in-network hospital? Or are you willing and able to pay the cost of using a facility that is out-of-network?
  • What is the premium cost?
  • Is there a deductible? If so, what is it?
  • Are there co-pays? If so, what are they? Do they count toward the deductible?
  • What is the co-insurance?

More information is available to help you

Here is a list of helpful resources:

If you have questions regarding Mercer Health billing or network status with different plans, we are happy to help you find the answers. Please contact us at myhealth@mercer-health.com or 419-678-5151.