Open enrollment is approaching for many people, including those selecting employer-sponsored health insurance and those reviewing their Medicare coverage for the upcoming year. Medicare’s open enrollment runs October 15 to December 7.

Choosing a health plan during open enrollment can be confusing. While the monthly premium is important, it is only one part of what your healthcare may actually cost. Copays, deductibles, provider networks, and authorization requirements can all affect both your expenses and your ability to receive care when you need it.

We have seen patients choose a plan because the monthly premium appeared affordable, only to later discover higher-than-expected copays or restrictions on certain services.

For example, if you are planning a major procedure such as a total knee replacement, you may need several weeks of physical therapy afterward. One insurance plan may have a relatively low physical therapy copay, while another may require a much higher copay for every visit. Some plans may also require prior authorization before or during your course of treatment.

Understanding a few basic insurance terms can help you ask better questions before choosing your coverage this open enrollment.

Common Health Insurance Terms for Open Enrollment

Premium:
The amount you pay to maintain your health insurance coverage, usually expressed as a monthly cost. A lower premium does not necessarily mean that the plan will cost you less overall.

Deductible:
The amount you may need to pay for covered healthcare services before your insurance begins paying its share. Not every service is necessarily subject to the deductible, so it is important to review the details of your specific plan.

Copay:
A fixed amount you pay for a covered healthcare service. For example, your plan might require a $30 copay for a physician visit and a different copay for physical therapy.

Coinsurance:
Instead of a fixed dollar amount, some plans require you to pay a percentage of the cost of a covered service. For example, if your coinsurance is 20%, you are responsible for 20% of the covered cost.

Provider Network:
Insurance plans contract with certain physicians, hospitals, therapists, and other healthcare providers. These are considered “in-network” providers. Depending on your plan, receiving care outside the network may cost more or may not be covered except in certain circumstances.

Prior Authorization:
Some insurance plans require approval before certain services can be covered. For physical therapy, some plans require authorization before treatment begins, while others allow an initial evaluation or a limited number of visits before authorization is required.

Authorization requirements can sometimes delay care, particularly if the insurer requires additional documentation before making a decision. This may be especially important if you anticipate needing rehabilitation soon after surgery. When comparing plans, ask whether physical therapy requires prior authorization and when that authorization is required.

Maximum Out-of-Pocket:
This is the maximum amount you are responsible for paying during the plan year for certain covered services under your plan. What counts toward this limit varies by plan.

Questions to Ask Before Choosing a Health Plan

During open enrollment, rather than looking only at the monthly premium, think about the healthcare services you are likely to use during the coming year. Some helpful questions include:

  • Are my current doctors and healthcare providers in the plan’s network?
  • What is my deductible?
  • What are my copays or coinsurance for primary care, specialists, physical therapy, imaging, and hospital services?
  • Does physical therapy require prior authorization?
  • What is my maximum out-of-pocket expense?
  • If I am planning surgery, what would I pay for the surgeon, hospital, imaging, and rehabilitation?
  • If I am having surgery, can my surgeon or physical therapist request authorization before surgery so that rehabilitation can begin promptly afterward?
  • Are my regular medications covered, and what will they cost?

A Special Note for Medicare Advantage Patients

Medicare Advantage plans can differ significantly in their provider networks, copays, coinsurance, and authorization requirements. A plan with a low or even $0 additional monthly premium does not necessarily mean that your overall healthcare costs will be lower.

If you are considering a Medicare Advantage plan during open enrollment, look beyond the premium and consider how you actually use healthcare. Check whether your physicians, specialists, hospitals, physical therapists, and medications are covered and what your costs would be if you need those services.

The bottom line: The best way to compare health plans during open enrollment is not simply to ask, “What is my monthly premium?” Also ask, “What will this plan cost me when I actually need healthcare?”

If you have questions about whether your plan covers physical therapy at Apex Physical Therapy Specialists in Honolulu, see our insurance page or contact us. We’re happy to help you understand your benefits before you need care.

This article is for general education and isn’t insurance, legal, or financial advice. Plan details vary, so confirm coverage, costs, and authorization rules directly with your insurer or plan administrator.