This article is about Justworks PEO. What product am I using?
We know picking a health insurance plan isn’t exactly the easiest thing on your to-do list. This guide is packed with everything you need to pick the plan that’s right for you.
Common Terms
Here are some common health insurance terms you’ll come across during Open Enrollment.
| Premium |
This is the monthly cost of your health insurance plan. It comes out of your paycheck before taxes are taken out. Premiums are based on four tiers:
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| Out-of-Pocket Max |
This is the most you’d have to pay for qualifying services in a calendar year. The carrier covers 100% of the cost for qualifying claims once you hit this amount. FYI: all of the plans we offer have embedded out-of-pocket maximums. That means you’re only responsible for hitting your individual out-of-pocket maximum, even if you’re on a family plan and the family out-of-pocket maximum isn’t met. |
| Copay | This is the amount you have to pay at your actual appointment. It counts toward the out-of-pocket maximum but not towards your deductible. |
| Coinsurance |
This is the percentage of the cost of a service the carrier will cover after the deductible (if any) is met. For example, let’s say your plan has 80% coinsurance. After you meet your deductible, the plan will pay 80% of the service and you’ll have to pay the remaining 20%. |
| Network & Plan Types | These are the facilities, providers, and suppliers your plan has contracted with to provide health care services. Networks are also commonly associated with the type of plan offered with that network. The main differences between them are the cost of the policy and where you can receive coverage. Learn more about the different plan types and how they work. |
| Flexible Spending account (FSA) / Health Savings Account (HSA) | Think of these as pre-tax piggy banks for healthcare needs that you can use to pay for anything health-related–from inhalers to lip balm — well into retirement! If your employment ends, an FSA lives with the employer, so you won’t be able to keep any unused funds. But, an HSA lives with you so you can keep the funds you’ve saved. |
For more terms and details see our Health Insurance Glossary article or this detailed Health Insurance Enrollment Guide.
All About Deductibles
A deductible is an amount you have to spend each calendar year before your health insurance starts to pay portions of your bills. After you pay, or meet your deductible, you usually pay the coinsurance and any copays–up to the out-of-pocket maximum. If there are multiple people on a plan, each individual will have a deductible as well as a combined family deductible.
Timeline
Here’s where things get interesting. The new health insurance plan you select takes effect on November 1, but deductibles don’t reset until January 1. Let’s take a look at the timeline:
New Plan Starts on November 1st
If you stay with the same carrier, everything you’ve paid towards last year’s deductible carries over to the new plan.
Deductible Resets on January 1st
Your deductible resets and you start paying into it again.
Plan Year ends on October 31st
Time to get ready for the new plan year.
Note: If you have an Open Market medical plan through the PEO, you may have a different plan year than November 1-October 31, but your deductible will still reset on January 1 regardless.
What happens if you select a plan with the same deductible?
If you pick the same deductible as last year, any funds you've paid towards the previous deductible will go towards your new deductible beginning November 1st. Then on January 1st, your deductible resets and you start paying into it again.
What happens if you select a plan with a different deductible?
Good question. Let’s say, for example, Sam is enrolled in a plan that has a $1,000 deductible. Come November 1st, Sam has met their deductible but has selected a new plan with a $3,000 deductible.
Deductibles reset on January 1st, so the $1,000 Sam has already paid would carry over into the new deductible. From November 1st to December 31st, Sam would have to pay the other $2,000 into their deductible before the insurance company begins to pay or before it resets on January 1st.
Learn more about Deductibles in our Help Center article here.
Questions to keep in mind
Would you rather pay more upfront or later on?
When picking health insurance, we’re often forced to choose between paying more upfront (in the form of a higher monthly premium) or paying more later on (in the form of a higher deductible). How do you choose?
More upfront: If you expect a lot of doctor visits or need regular prescriptions, you might want to consider a plan with higher monthly premiums and lower deductibles that pay more of your costs when you need care.
More later on: If you don’t expect to use regular medical services and don’t take regular prescriptions, you might want to consider a plan with a lower monthly premium and a higher deductible.
Taking specific medications? Any major life events coming up? Planning any procedures?
For medications, check the drug formularies associated with the plans you're considering. If you’re getting married, do you want to keep separate plans or get joint coverage? If you’re thinking of starting a family, compare fertility, prenatal, and postnatal service coverage, as well as delivery and inpatient services. If you’re planning any surgeries or procedures, be sure to check the summary of benefits and coverage for the plans you’re considering to see how much of the cost of your procedure is likely to be covered.
How can I tell if my doctors or prescriptions are in-network?
Visit our Finding a Provider Help Center article for a full list of resources~
When can I enroll in an FSA or HSA?
FSAs are based on the calendar year. Open enrollment for FSAs will be in December for the new plan year starting January 1.. HSAs can be added at any time if you enroll in an HDHP and your employer offers one.
I have questions about specific medical services, procedures, claims, or costs. Who can help me?
This is a job for Health Advocate–a third-party resource that’s automatically available to all employees at no extra cost. They can help answer questions about plans and claims, and provide help for finding specialists who accept your insurance. You can reach them at (866) 695-8622 or answers@healthadvocate.com.
Specific medical services, procedures, claims, and costs are all considered to be “Protected Health Information” and can only be discussed with a HIPAA-compliant resource.
Why might my plan’s monthly premium be going up?
A cost increase could be the result of a change in an employer’s contribution or the overall rise in the cost of the plan. Every year, a component of all rate increases is the overall rising cost of health insurance in the U.S. All employers’ renewal rates are impacted by market forces–like healthcare and drug inflation which continue to outpace the general inflation rate–and a healthcare landscape that is constantly changing. Other factors that may impact costs are new and changing legislation, advancements in prescription drugs/medical equipment, the cost of care, and the performance of plans.
If your plan no longer meets your needs or your budget or you’d simply like more help navigating your options, Health Advocate can provide support in picking a plan that’s right for you.
If I decline to renew my coverage, am I still able to seek coverage elsewhere?
Yes, if you are currently enrolled for medical insurance but do not renew it, you can use your termination of coverage letter from the carrier to seek coverage through the marketplace. If you are eligible to be a dependent on someone else’s plan (like a spouse or parent), you can also use your termination of coverage letter to enroll for their plan. If you decline coverage, you will not be eligible for COBRA.
I’m having trouble making my selections in Justworks. Who can help me?
Justworks Support is available at support@justworks.com or (888) 534-1711. We’ll be happy to help you figure it out.
Disclaimer
This material has been prepared for informational purposes only, and is not intended to provide, and should not be relied on for accounting, legal or tax advice. If you have any legal or tax questions regarding this content or related issues, then you should consult with your professional legal or tax advisor.