Welcome to Open Enrollment with Justworks!

Use this guide to navigate the how, what, and why of health insurance plan selection.

Enrollment 101

In this section, you’ll find some definitions of common health insurance terms, answers to a few frequently asked questions, and information about how to read a health insurance plan in Justworks.
This is the percentage of the cost of a service or fee your insurance carrier will cover after your deductible (if any) is met. For example, if a plan has 80% coinsurance, the carrier will cover 80% of the cost of the service and the remaining 20% would be paid for by you.
Typically, the coinsurance coverage for out-of-network services will be significantly lower than for in-network services, making out-of-network services more costly for you.

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A copay is the fixed dollar amount you have to pay for a specific type of service, for all plans except HDHPs. Copays count toward your out-of-pocket maximum but not your deductible.

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This is the amount of money you must pay out-of-pocket for covered health services before your carrier begins to pay. After you meet your deductible, you usually pay your copay or coinsurance, up to the out-of-pocket maximum. Typically copays will not apply toward your deductible. Health insurance plans will have a deductible for each individual on a plan, and a combined family deductible.
If you decide to switch plans during open enrollment, you’ll have a deductible credit for what you’ve already paid towards the deductible this calendar year on your current plan applied to your new plan until January 1. January 1 will mark the restart of your deductible accumulator for the new calendar year.

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In-network refers to a group (i.e. network) of health care providers or facilities that have pre-arranged agreements with your health insurance carrier to provide services at discounted rates under your specific plan. Out-of-network providers/facilities are those that don’t have an agreement with your carrier for your specific plan, and therefore usually provide services at a higher cost than those who are in-network. Some plans will not cover any costs for out-of-network care.

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This is the most amount of money you would have to pay for qualifying services in a calendar year. Once you’ve met this amount, your carrier will generally cover 100% of the costs for subsequent qualifying procedures and charges.
Out-of-pocket maximum accumulators reset each year on January 1.

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SBC stands for Summary of Benefits and Coverage, a document with a short, plain-language overview of a plan’s benefits and coverage that insurance companies and job-based health plans must provide. SBC’s also generally include detailed examples of what a plan would cover in certain common scenarios, such as childbirth or diabetes care.

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An EPO, or Exclusive Provider Organization, provides in-network coverage only without pre-authorization (there may be an exception for out-of-network coverage in life or death emergencies).
An HMO, or a Health Maintenance Organization, includes regional networks with a limited number of providers, and the plans always require a referral to see a specialist.
A PPO, or Preferred Provider Organization, is a health care organization that has agreed to provide health care through a network. Care may also be provided by out-of-network providers but higher fees may apply.

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HDHP stands for High Deductible Health Plan. According to IRS rules, 2020 HDHP plans must have a minimum annual deductible of at least $1,400 and an out-of-pocket maximum on in-network expenses of $6,900 for the employee-only tier of coverage. With the exception of preventative care, the coinsurance and all cost sharing will not apply to any services before the deductible has been met. You may be eligible to contribute to an HSA if enrolled 
in an HDHP.

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A Flexible Spending Account, or FSA, is an employer-owned account that allows eligible employees to save pre-tax money to pay for out-of-pocket health care costs. An FSA can be used for deductibles, copays, medication, and other health care related out-of-pocket costs, and all money deposited is untaxed. Funds generally do not carry over from year to year.
A Health Savings Account, or HSA, is an employee-owned account used to save pre-tax dollars for health costs. Contributions can come from various sources, and HSAs can be used to make investments, similar to a 401(k) and an IRA. These funds then grow in the account completely tax free. To be eligible to contribute to an HSA, employees must be enrolled in a high deductible health plan (HDHP) that is HSA compatible. Funds carry over from year to year.

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During the open enrollment period, you'll be able to change or reset your plan selections within Justworks if you change your mind. Just make sure to change and finalize your plan selection before the end of the enrollment period. After that date, you won't be able to change your plan unless you experience a Qualifying Life Event, or QLE.
There are many people and resources available to support you through this process! We've created a simple directory with more details and contact information.

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Choosing Your Plan

In this section, we’ll dive into more personal scenarios you might be encountering or specific questions you might have based on your current life-stage.
A couple other things to keep in mind:
If you do add your spouse to your plan as a dependent, don’t forget to cancel their previous coverage, if any. If your spouse retains outside medical insurance and is added to your medical plan, one of the plans would be considered primary. This has an impact on how each carrier may reimburse you or how much they may cover your spouse’s care.
If you’d also like to add your dependent to your vision and dental insurance plans in addition to your medical plan, be sure to add them to those plans in the Justworks enrollment flow.
You can find general information about pregnancy-related coverage in the Plan Details section or Summary of Benefits and Coverage document for each plan. We've also created a discussion guide and checklist of potential childbirth-related medical expenses, as well as a short course on financial planning for first-time parents.

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Example of pregnancy/childbirth coverage information in an SBC.
If you're adding a child to your plan for the first time, it's always a good idea to search the plan's network to see if your child's pediatrician (if you already have one) is in-network or out-of-network. You should also consider the various pediatric services you may need, and review the costs associated with those services. Some plans will cover a higher percentage of the cost for these services than others, and some may not cover them at all. To learn more, you can review the Plan Details and Summary of Benefits and Coverage (SBC) documents in Justworks, or contact Health Advocate for additional help.
Be aware that if you're moving to an employee + children or family plan from a different enrollment tier, there will be a change in cost, which will impact your paycheck deductions. You can review the plan costs at each tier directly in Justworks in the enrollment flow.
Check the “Plan Details” section in the Justworks enrollment flow and look for the section titled “Mental Health Services.” There, you’ll see what you’ll have to pay for mental health providers that are in-network or out-of-network under a specific plan. You’ll be able to compare copays for in-network coverage across different plans. The “Summary of Benefits and Coverage” (SBC) for each plan is located in the employee documents section in Justworks, and will also include information about mental health coverage.
Example of where to locate Plan Details
Example of what a mental health coverage section looks like in Plan Details.
Check each plan’s “Summary of Benefits and Coverage” (SBC) document and look for the section labeled “If you need drugs to treat your illness or condition” (see example screen above) to get general information about prescription coverage. Then, check the carrier's preferred drug list to see how the drug is classified and to find out the rate.
Aetna: Find detailed information on prescription coverage in the plan details PDF for each plan. Use Aetna's Find a Medication tool to find a specific drug and its price, under your plan found on both Aetna Navigator and the Aetna Mobile app.
Kaiser Permanente: Kaiser’s formulary is a list of drugs that have been approved for members by the Kaiser Permanente Pharmacy and Therapeutics Committee.
UnitedHealthcare: You can search for network pharmacies through OptumRx, the pharmacy care services manager for UHC plans. UnitedHealthcare also provides a Prescription Drug List, which is a list of commonly prescribed medications covered by the plan. Medications are put into tiers that determine their cost.
First, find the plan or network name at the top of the Plan Details document in Justworks. Your current network is also listed in the “Benefits” section of your Justworks account. Then, go to the relevant provider’s website to search and see if your doctor or specialist is listed as "in-network" for the plan you selected.
Search Aetna’s directory.
Search Kaiser Permanente’s directory.
Search UnitedHealthcare’s directory.
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.
No, you would not be eligible for COBRA at this time, since you would be voluntarily declining your coverage.
Not all employees will see an increase in their monthly contributions, as it depends on the employer contribution and plans being offered. A cost increase may 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.

Download our directory for info on how to contact Health Advocate.

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Want a PDF takeaway?

Our guide, Understanding Open Enrollment, includes a step-by-step walkthrough of how to sign up for health insurance in Justworks.
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