Hey there, welcome to Paging Dr. Gupta. This is one of my favorite shows because I get to answer your questions about health and today we've decided to tackle a big one. It's an issue that I know is on many of your minds this time of year and frankly, it can be even spookier than Halloween. I am talking of course about open enrollment. And if you're anything like me, you might be doing your best to avoid even thinking about this.

What I worry about right now, and particularly in this season of renewing insurance, is that people avoid going to see doctors and avoid going to the hospital because they're just afraid of the bad experiences they've had.

To help me explain it, I've invited Dr. Elisabeth Rosenthal. She is a doctor, she's a journalist, she's an author like me. She spent 22 years at the New York Times. Now she's senior contributing editor at KFF Health News. She is the bestselling author of a book called An American Sickness: How Healthcare Became Big Business and How You Can Take It Back.

I'm just trying to figure out how to make it better for people, which has kind of been my journalistic mission for decades.

She will take us through the ins and outs of open enrollment, hopefully helping you get through it, right after this short break.

In the spirit of trying to demystify some of this, and myself included, and I'm reading these manuals like everyone else and thinking, you know, which one should I do? First of all, what is open enrollment and why is it one time a year?

Open enrollment is a period of the year where you can sign up for a new insurance plan or renew your current insurance. And it's one time a year because what the insurers don't want you to do, which I get and which is reasonable, is to go without insurance, get diagnosed with cancer, and then go, oh, now I'm going to buy a really good plan. So it's supposed to be pooled risk, right? So it's open for a limited time of year. For most of the country, it starts November 1st. There's some variation, but it's a really, really important and really, really stressful time of year for people and twice as much this year or exponentially more this year.

But there are things known as qualifying life events.

Yes.

So what are those? What would allow you to buy healthcare insurance at a time outside of open enrollment?

Yeah, outside of open enrollment, there are, you know, if you get married, you get divorced, you lose a job, you have a baby. There are all these things that obviously would change your ability to have insurance. So at those times, if, if experience one of those qualifying life events, yes, you can go back on the market and buy insurance. COBRA is an option if you lose a job or if you're a kid who falls off your family's insurance. It basically allows you to stay on a company plan, but you will be paying 100% of the premium. Usually your company is contributing a significant amount to that premium, so the costs will go way, way up. The amount of time that companies will let you COBRA for varies a lot but it's going to be very expensive to do so.

'Where is this market where you go to get insurance? Well, unless you have private or employer-based insurance, or if you're on Medicare or Medicaid, to buy health insurance, most people are going to visit the ACA marketplace, sometimes called the exchange, which opens up, as Dr. Rosenthal said, on November 1st in most states. Now, I will point out 32 states use the federal marketplace. That's at healthcare.gov. And the rest have state-run marketplaces. If you're not sure, visit healthcare.gov and see if your state pops up.

When you're shopping on the marketplace sites, you know, it's confusing too because some states have their own marketplace sites that are different from the federal one. There are two buttons that people should know about. One is ask for more help. And there are people called navigators or assisters, and I hope still in every state. In most states there are, President Trump and his administration pulled a lot of the funding for them. But they really know these sites like the back of their hands and can really help you if you reach out to them. But most people don't know they exist. And if they do, on many exchanges and in many states, the ask for help button can lead you to an insurance broker who may just work with one of the big insurers and not be on your side. So look for navigators or assisters to help and use them. And that means don't wait till like December 31st to do.

I wanted to make sure you caught that: navigators and what are called assisters can help you. But also you'vt got to be careful because depending on where you live, you might be getting connected to an insurance broker and they may be working on commission or they may working with a big insurance company or steer you toward a more expensive or less than ideal for you plan. So you have to ask, who exactly are they working for?

People want to know if their doctor is going to be covered by their healthcare insurance that they're selecting. And sometimes, I mean, you can call the doctor's office and ask, do you take this healthcare insurance, right? But is there an easier way or a consistent way to figure that out?

'Well, I, for example, just found out that my insurance had changed specialty pharmacies by not being able to get a drug that I needed. So I think many people will find out the hard way. On most sites, they have a button that you can push that tells you who is in network and who's not. And that's kind of cumbersome to do. But there are searches on those pages that you can put in your doctor and say. Is my doctor in my network for this year? Because remember, it can change year by year. I mean, the ridiculous thing is it can change mid-year even though your insurance can't change. That's not a qualifying life event if your doctor moves. But I think it takes a lot of work. We shouldn't put so much responsibility on patients. I mean it's so much detective work, and I hate to like even say, this is what you should do because you shouldn't have to. But you look for your doctor, then you look for the hospital you prefer to make sure it's a network, and you have to double check. For example, if it says Presbyterian Hospital, well, Presbyterian Hospital probably has 30 outposts, and you to make it's the one near you or the mothership if you want that. If you have kids, you should want a network that has a children's hospital, And if you want a particular cancer center, you should make sure the network has that. So there's a lot of choice, and the more choosy you are, the more you're going to pay. So you know, there is a trade-off there.

It's a lot of work but you can find the answers to those questions if you if you spend the time and navigate through the site

Yes, in theory, you know, my son buys insurance on the exchange and he uses a navigator. He said, can you help me do this? And I know a lot about this, but I'm not an expert in the New York state marketplace. So which, by the way, some of the state marketplaces are not even called like this is the state marketplace in New York. It's called the New York State of Health. In in Maine it's called MaineCare so you have to know what the name of your state's marketplace is to even make sure you're on the right shopping site, a legitimate shopping site.

I can't underscore this enough. Make sure you are on your state's official Affordable Care Act marketplace, not an insurance broker's website. And as Dr. Rosenthal said, it may have an unusual name.

Are there public options in all the states?

No, very few at the moment.

It is an ongoing project that Colorado and Oregon, I believe, are experimenting with. There's a bill to get that going in New York, but so far not.

But it sounds like from what you're saying, even if you did have a public option in New York where you live, you would still have to navigate through some of these things, because it doesn't sound like it means automatically your doctor or hospital system, specialty care, pharmacy would necessarily all be covered.

'No, I think a public option would mean kind of the opposite. This is what we give you as the public option. If you're happy enough with that, you can take it. And it's going to be predictable. The co-pays will be low. It will not have a high deductible if it has a deductible. But it will be a limited network. But for a lot of people, that would be fine. They know they have health insurance rather than none at all.

If you miss open enrollment, if you do nothing, let's say you have healthcare insurance, you did open enrollment in the past, but you forget to do it this year, you just don't get around to it, what happens?

Uh, you're in trouble.

I mean, does it roll over or are you in trouble?

You really have to know your plans. Some plans will automatically roll over if you don't choose another plan. Some plans may not. Other plans may stop participating in the exchange. So they won't exist in your exchange anymore. So that's not an option. And you know, you may have gotten a notice in the mail with the stacks of stuff you get these days saying, by the way, we're not participating in health care plans in your state next year. So I tell everyone, you know, unfortunately if you see a health care thing on an envelope you should open it to see what it says.

Okay, that's really good advice. Don't throw those that, especially this time of year.

It's tempting to throw them away.

Up next, a lightning round of glossary of terms. That's after the break.

Welcome back to Paging Dr. Gupta. Today we are answering questions about open enrollment coming soon to a marketplace near you. My guest and guide is doctor, journalist, and author, Elisabeth Rosenthal. She's taking us through the ins and the outs, starting with a type of plan that may Sound great, but has potential pitfalls.

'There are these things called short-term health plans, three-month plans, which were not legal during the Affordable Care Act, which you can buy. They are more expensive. They do not comply with ACA basic standards. So, for example, the ACA requires all plans that are under its purview to provide certain basic health services, like pregnancy care, like vaccine- vaccinations, like preventative care. The short-term health plans may not do that. They may also be very limited to one state, so, you know, you're traveling and you get hurt and you're out of luck.

I don't know how old your children are. I guess you said they were born in the 90s, but I have at least one now in her 20s. Talk to me about the age of 26. What happens then?

'Yeah, the ACA said that at 26 you have to get off your family's plan and That was a great decision at the time because often at the young adults had to get of their plan at 18 or 20. So extending it to 26 got a whole lot of young adults insured who otherwise probably wouldn't have been. But the assumption at the which proved not to be so accurate was that by 26, the assumption of the ACA is that all states would expand Medicaid. So if someone wasn't earning a lot of money at 26, they could go on Medicaid. If you're a kid's an actor or writer or something like that, the other assumption was that the ACAs exchanges would offer good affordable options for 26-year-olds. At that point if they made too much money to go on Medicaid. And in the aftermath of that, the Republican Congress, with President Trump's urging, kind of kneecapped the ACA. There was a requirement in the ACA that said everyone has to buy health insurance. There was requirement in ACA that all states should expand Medicaid. There was funding of navigators, there was prohibition of short-term plans, and it was expected that there would be much better regulation on the exchanges by now, and that has not proved the case. And of course, healthcare costs have spiraled, as have premiums, so now people hit 26, and they're really struggling. They don't have the options that we expected they would. So I think, you know, again, oh yeah, sure, we could raise the age 'til 30, but that could go on at infinitum. So it's a problem that we haven't solved, particularly because as the gig economy has risen, a lot of jobs that young people have don't come with insurance. Any company with under 30 employees doesn't have to give insurance to its employees. So, if you're a startup or you work delivering packages, you don't have health insurance. One young woman said to us, you know, I felt like throwing my head into my birthday cake and saying, I don't health insurance, you now, it's not a happy birthday anymore.

Right, right. Let me let me go through some essential terms just for a second here. Sure. Quickly, HMO versus PPO.

'Oh, an HMO has a much more limited network, and you really can't go out of it. You know, you have to stay in network. That doesn't mean it's necessarily bad. You know Kaiser Permanente, which has no relation to KFF, is an HMO that a lot of people like being in because it has a wide array of hospitals and providers in California, in particular. We tend to use it as a pejorative term because many HMOs have not been very good, but some have been. A PPO, it's a Preferred Provider Network. And in a PPO you have a broader range of doctors, you have some coverage typically for if you're going out of network, it may be your insurer will pay 70% out of network in the full cost of in-network. So that's a PPO. And you know. It's nice if you can afford the out-of-network charges and the higher premiums that will come with that.

So that gives you more flexibility though, if you think you're going to need to leave your network.

'Yeah, and in some cities, you know, it's very hard to stay in-network. In some cities there are not a lot of in-network obstetricians or in-network dermatologists, so you often have no choice.

HSA versus FSA.

'An FSA is money that you elect to put aside each year to use for health care costs and you know, it's a portion of your salary that you put aside tax-free through your employer and you can use it, you know for a wide range of things, buying glasses, you know, over-the-counter drugs at the pharmacy. The catch with the an FSA, is it's use it or lose it. So. Goes on for a year. There's often a grace period of a few months, but if you don't use it up by the end of that term, your employer gets back the money. So if you have a year where you're really healthy and don't need much, you find yourself at the end of the year like scrambling to like buy new sunglasses or

'Over-the-counter medicines, whatever.

'Yeah, stock up on gauze pads or something. And HSA is something that rolls over, it's the same idea. It usually comes with a high deductible health plan. It's usually paired with that. And it's, again, tax-free money you put aside to pay for healthcare costs. And it does roll over. So the HSA money you keep from year to year. And that's, it's like a really nice idea. Say you make $100,000 and put 5% of that into an HSA. There's usually a limit on how much you can put in an HSA each year. You know, in a country where having your gallbladder out costs $30,000, it's hard to rack up enough money in your HSA to like really get you out of trouble.

But it can help offset the cost of deductibles.

Yeah, of course. Of course.

Do you do an HSA or FSA?

My company has an FSA, so I do an FSA.

One more and you talked about this earlier, but deductible versus premium.

'A deductible is basically what you have to pay before your insurance even kicks in for anything. People will often say, what, I thought I had insurance and I got a bill for $5,000. Well, if you have a high deductible plan, that can happen and hopefully you have an HSA to make up some of that difference. The premium is what you pay each month to have insurance basically. The lower the premium, the higher the deductible, so I always tell people, don't just look at the premiums. That's the thing that will get you in big trouble. Look at the premium and the deductibles, and you have to look at the co-pays are usually minimal. They're usually not that much, you know, they're $25, $50. They've gone up, but they're never - I haven't seen really outrageous co-pays, what you pay when you go to a doctor's visit or go to an ER. What has emerged as a big thing is called co-insurance, which is kind of a novel aspect of insurance. There are all these innovations which come out of industry. So co- insurance is a percent of the bill you have to pay, even if you have insurance, and it's often 20 percent, right? And if you're in the hospital for two days, 20% is probably 5, maybe even $10,000. Now what will save you on many plans is most plans have an out-of-pocket maximum. So it will say, once you spend $20,000, your insurance has to cover the rest. So if you have a serious illness over the course of the year. You know, you'll hit your out-of-pocket maximum, no doubt, and the rest will be paid for you. The ironic thing is for some drugs, like for really expensive drugs, like the hemophilia drugs, those patients will hit their out-out-of pocket max by February because the drugs are so expensive and their patient contribution is so high. So, there are all these complicated things to think about when you look at a plan.

'So co-insurance sounds very much like deductibles.

Yes, but a deductible you know how much it's going to be when you sign up for a plan. The coinsurance you know what percent it's going to be, but depending on what your experience is in hospitals or clinics, the amount can change dramatically.

There is one more term Dr. Rosenthal wants you to know about, The No Surprises Act.

'Another favorite of mine. One of the lights in the darkness for patients, I think, of the last few years, what the No Surprises Act does is it protects patients from out of network bills when they go to an in-network hospital or in an emergency. So you know, if you're unconscious and you're taken to out-of-networks hospital Y. Out-of network hospital Y can't bill you as an out of network patient. They have to bill you an in network patient. Likewise, when you go to an ER, and the ER is in network, and suddenly the doctor who's seeing you, who you have no choice about, is out of network. That led to huge bills in the past, because they could bill whatever they want. That can't happen anymore. So there are a lot of variants of surprise bill that are not covered, you know, so it's a step in the right direction, but there's a lot more to do.

Well, I really appreciate you talking us through all this, fingers crossed for what happens over the next couple of weeks. And I think we're all smarter about open enrollment, myself included, in terms of how I'm going to navigate some of that this year.

Good luck, good luck.

I mean, yeah, even you, even the great Elisabeth Rosenthal had trouble with her open enrollment finding that specialty pharmacy. So it can happen to anyone, sounds like, but you've got to spend the time doing it.

Yep, absolutely, it's worth the time.

Thank you, Doctor.

Thank you for having me.

'That's our show for today. I hope you got something out of it. I know I did. It is time for open enrollment, so don't put it off. If you want to hear more, you can go back and listen to part one of my conversation with Dr. Elisabeth Rosenthal. We discussed the history and the politics of healthcare. How did we get to this point? You can look for it in the Chasing Life feed. In the meantime, if you have a health question that has you scratching your head, send it our way. Record a voice memo, email it to asksanjay@cnn.com, or give us a call, 470-396-0832, and leave a message.