Understanding Open Enrollment

October 01, 2012

The Basics: What You Need to Know

Open enrollment is the time of year when your employer advises you of the various benefit packages that they will be offering. These packages include your health coverage. The choice you make will be with you for the entire year, so it’s important to weigh your options. Careful consideration of the following criteria can help you choose the right insurance plan.


“Cost is at the front of everyone’s mind, but remember that a lower monthly premium might result in higher deductibles and/or co-payments,” says Karen Carrol-Kowalski, director of marketing and customer service for Facey Medical Foundation, the operational side of Providence-affiliated Facey Medical Group. She recommends a two-part analysis. First, honestly assess your health. Second, scour coverage options for the cost of benefits you may need.

For example, if you’re healthy, pay attention to what the cost would be for annual physicals or if you had to have emergency surgery. If you’re planning to start a family, scrutinize covered benefits such as cesarean sections and inpatient hospitalization costs. If you have a chronic health condition, note the applicable co-pays, deductibles and coverage for lab work, prescriptions, office visits and hospitalization. Take into account what would fall outside the plan and would require additional payment.

Find the Right Physician

The first question many ask during open enrollment season is, “Can I see my current physician under this plan?” If you don’t have a doctor, open enrollment is a great opportunity to select a Providence-affiliated physician.

“It’s critical for an individual to select a health care team—starting with your doctor—who will work with you to maintain good health and tackle medical issues as they arise,” says Jeffrey London, M.D., medical director of Affiliates in Medical Specialties, a member of Providence Medical Institute (PMI). PMI is a network of clinics and urgent care centers located throughout the region.

Remember, you will not be “locked in” to the physician you select at open enrollment. Neither, however, do you want to be “locked out” from access to your preferred physicians by choosing a plan not contracted with your hospital of choice. “If you do choose a Providence physician as your primary provider, then you’re already covered by primary care, specialty care and ancillary care under the Providence umbrella,” says Ron Robinson, administrator of Axminster Medical Group, which became affiliated with PMI last year.

This is why, Carrol-Kowalski says, it’s important to investigate your insurance options. “If it’s 4:45 p.m. on the last day of your employer’s open enrollment period and you throw a dart at your options, you might choose a plan that does not allow you to see the physicians you want. Make sure your preferred physician and your preferred hospital are on your plan,” she advises.

Accessibility to Providence Care

The selection of your physician goes hand-in-hand with access to your preferred hospital. Make sure any health plan or physician group you choose includes a Providence medical center.


  • Providence medical centers draw upon each other’s strengths. When you’re connected to Providence, you’re connected to its continuum of specialty services and expertise. Providence hospitals and physician groups complement each other’s services and work closely with each other to enhance care.
  • Your favorite physician may not be on staff at your favorite hospital. If you have a preferred hospital, based on quality and compassionate care, it is important to ensure that your physician, or a hospitalist who works with your physician group or knows your physician, can care for you there during your stay. Some insurance companies limit their physicians to practice at certain facilities. A Providence affiliated physician can coordinate your care from outpatient evaluation and subspecialty referral needs to inpatient care, creating the best health care team to address your needs.
  • Growing numbers of physician groups are aligning with Providence. Providence Care Network (PCN) was established in 2011 to deliver Providence quality health care. It represents close to 40 primary care and more than 200 specialty physicians. Affiliates in Medical Specialties was one of the original PCN members.

Dr. London says joining PCN made sense for many reasons, including the excellent communication between physicians’ offices and Providence medical centers, as well as Providence’s calling to deliver health care to those in need. “I’m very proud about that as a physician of Providence. It should give patients the additional confidence to know that Providence’s goals and spirit are in the right place.”

Bringing all of this together is Providence Partners for Health (PPH), a partnership among Providence Health & Services, Southern California, and area doctors. More than 660 physicians are associated with PPH, which connects providers and the hospitals electronically, fostering more accountability and consistent, high-quality care. “We want the same things patients want—physicians who communicate with one another, have access to information important to patient care, and are dedicated to providing exceptional care while reducing costs,” says John Armato, M.D., an endocrinologist at Providence Little Company of Mary Medical Center Torrance.

What About Medicare?

Initial enrollment for Medicare age-in plans —plans for those turning 65, or “aging in” to Medicare—occurs three months prior to your 65th birthday. Joining during this time period will allow you to have Medicare coverage the first day of your birthday month. You are also able to enroll, with no penalty, the month of your birthday and/or three months after—however, your coverage will be delayed.

For existing Medicare recipients, open enrollment occurs annually from Oct. 15 through Dec. 7. “Recipients of Medicare are able to change doctors or medical groups any time they want throughout the year. However, changes to their health insurance plan can only happen during that window,” Carrol-Kowalski says.

The criteria for selecting Medicare coverage—cost and physician/hospital preferences—are similar to that for commercial plans, with special consideration required for prescriptions. Medicare Parts A (hospital insurance) and B (medical insurance) do not include prescription drug coverage. To obtain this coverage, you must join a Medicare prescription drug plan (Medicare Part D).

Consumers have another option: A Medicare Advantage Plan (Medicare Part C) includes both Medicare Part A and Part B and quite often includes Medicare Part D. Medicare Advantage Plans are offered by private insurance companies approved by Medicare. Through PMI, physicians are accessible to Medicare recipients who have Medicare Parts A and B and also to those recipients who have chosen to obtain coverage through Medicare Part C.

When researching prescription drug coverage, it is important to investigate the plans’ drug formularies. “This is especially true for people who may be on brand-name prescriptions,” Carrol-Kowalski says.

Your best reference for Medicare information is medicare.gov. Type in your zip code to review your health insurance options. You can also check your prescriptions to see which plan may have the best coverage.

One other twist is that some Los Angeles County Medicare recipients must consider a new pilot program for “dual eligibles,” or those who are dually eligible for Medicare and Medi-Cal. “The ultimate goal is improved care, better health and a better delivery system,” Robinson says, adding that in Los Angeles County there are 370,000 dual eligibles. By June 2013, all dual eligibles must sign up for a managed care plan or be assigned to one. If this describes you, be proactive to select a managed care plan contracted with Providence. For more information, visit calduals.org.

Finish Strong

After you’ve researched and selected the right insurance option for you, don’t let your efforts go to waste.

  • Examine your ID card to ensure the doctor you’ve selected appears on it.
  • Scrutinize your insurance packet to make sure it reflects the plan, deductibles and co-pays you’ve selected.
  • Finally, keep in the know about health care reform – and keep in mind that Providence Health & Services, Southern California is poised to adapt within the regulatory climate without sacrificing care, quality or its commitment to community. “Health care reform asks, ‘How do we deliver quality care efficiently in a safe setting?’ Providence is asking those same questions,” Dr. London says, “No one really knows what health care reform will look like in its final form. The details are probably not as important as the fact that we know medicine will change – and needs to change – to be more efficient, more convenient and more transparent.”