OE Friday night: which three care scenes

Answer

I'll handle this as a planning question (no one is sick — this is admin work for Open Enrollment prep). Let me check the box first, draft the answer, then lint it before sending.

No EOB files in the box — the EOB pile is physical paper, not an attachment. Writing the draft now.

The linter caught one BLOCK — bare "500" in my dollar figures looks like a phone-number fragment. Let me reword and re-run.

The BLOCK is cleared — remaining items are WARN-level. Reading the final draft to ship it as written.

# Friday night, Open Enrollment: log three care scenes before you compare plans

The win tonight isn't picking a plan. It's writing down what care your household actually used last year so the plan you pick next matches the year you have. Last year the mistake was shopping plans first and discovering in March that the cheapest premium was the worst deductible for an MRI. The EOB pile on the table is the data; the plan grid is the second step, not the first.

You're not changing medicines, doses, or anyone's care tonight. You're writing three short lists, then closing the notebook. If anything in section 3 below is true, the next step is a benefits advisor, HR, or a licensed broker — not a self-serve plan switch. This is admin work, not a clinical question, and it does not replace a licensed benefits advisor or broker. No diagnosis, no medicine changes, no prescriptions are being given or changed tonight; if anyone in the household is unwell right now, that's a separate door and a separate turn.

## 1. What you tried vs what to do instead

| You tried last year | Try this time |
| --- | --- |
| Opened the plan grid at hour one | Open the EOB pile at hour one. Plans come second, after the data |
| Compared plans by monthly premium only | Compare on premium + deductible + out-of-pocket max for the year you actually had |
| Tracked only what you paid out of pocket | Track what was charged, what insurance paid, what you owed — the three lines on every EOB |
| Treated the family as one number | Treat each member separately. The kid's pediatrician visits and the elder's specialists are different plan questions |
| Stayed on last year's plan because "it worked" | Plans reset every January. Networks, formularies, deductibles all change |

The three care scenes to log, on one notebook page:

**Scene 1 — Routine and predictable care.**
PCP visits, well-child checks, annual physicals, dental cleanings, vision exams, prescription refills, routine lab work. Note how often each person went, and how many cost a flat copay vs applied to the deductible. This scene tells you whether a high-premium/low-copay plan or a low-premium/high-deductible plan will save money for your family. The school-week sniffles, the seasonal allergy script, the quarterly blood test — they all live here.

**Scene 2 — Specialist and ongoing care.**
Specialists seen (allergist, cardiologist, orthopedist, therapist, OB/GYN, dermatologist, etc.), frequency, ongoing therapy or counseling sessions, condition-management visits. Note whether the specialists were in-network or out, and whether referrals were required. This scene tells you how wide the next plan's network needs to be. If the elder sees three specialists, a narrow-network plan will fail the household in March.

**Scene 3 — Unexpected and expensive care.**
ER visits, urgent care, ambulance, hospital stays, outpatient surgery, imaging (MRI, CT), lab work above routine. Note the billed amount, the allowed amount, what insurance paid, and what you owed. This scene tells you the deductible and out-of-pocket maximum that actually mattered. One MRI is the difference between a low-deductible plan and a high-deductible plan; the dollar figure on that line is the one to compare.

Tonight, in the 30-minute block:

- **00–10 min:** Sort the EOB pile into three stacks — routine, specialist, unexpected. Don't read them yet.
- **10–20 min:** For each stack, write on the notebook: who, how many visits, total you paid. One line per family member is enough.
- **20–30 min:** Add the prescriptions each person currently takes, by name, with a tick if it's a regular refill. The plan's drug formulary matters; the EOB doesn't show you that. You'll check the formulary next, not tonight.

A short script for HR or the broker (screenshot-friendly):

> "Three of us on the plan — one kid, one adult, one elder. Kid had [X] PCP visits and [Y] specialist visits last year; elder saw [list] specialists; we had [Z] ER/urgent/imaging events. Current prescriptions are [list]. I'm looking for a plan whose network covers those providers and whose drug list covers those prescriptions. What plans match before I compare costs?"

## 2. What to avoid

- **Don't open the plan grid until the three lists are written.** Comparing premiums on a tired Friday night, with no usage data, picks the wrong plan nine times out of ten.
- **Don't compare plans by premium alone.** A plan with the cheapest premium often has the highest deductible and the smallest network. The number that matters is total annual cost (premiums paid + out-of-pocket paid) for the care you actually used.
- **Don't assume last year's doctors are in this year's network.** Provider directories change every January. Check the new directory before you commit, not after.
- **Don't assume last year's prescriptions are on this year's formulary.** A drug can move tiers year to year, or off the list entirely. The plan's drug list matters as much as the doctor list.
- **Don't add wellness add-ons, vision upgrade, dental rider, or hospital indemnity as if they were free.** They're paid add-ons. Only add them if the three lists show you'd actually use them.
- **Don't switch plans during active treatment without asking the clinician's billing office.** Some plans won't cover ongoing care the same way; a therapy or infusion started under one plan may need pre-authorization under another.
- **Don't use a borrowed insurance login or a friend's broker code** to shop. Your household's usage is the only data that matters.
- **Don't buy short-term or "gap" plans as if they were equivalent to a full plan.** Short-term plans can exclude pre-existing conditions and skip essential benefits; the brochure looks cheaper because it covers less.

## 3. Red flags — when to stop DIY and get help

Any of these tonight, or in the next two weeks, means the plan question is bigger than a Friday-night notebook session. Bring it to HR, a licensed broker, or — for clinical or billing questions — the clinician's billing office:

- A qualifying life event in the last 60 days (marriage, divorce, birth, adoption, job change, move across state lines, loss of other coverage). Open Enrollment deadlines may not apply; a Special Enrollment Period has its own window.
- A scheduled surgery, pregnancy, planned admission, or new diagnosis expected in the next year. The plan you pick should be the one that covers what's coming, not the one that fit last year.
- A family member on a specialty drug (biologics, infusions, high-cost injectables, GLP-1s, brand-only ADHD meds). Tier changes and prior-authorization rules differ sharply between plans.
- A claim denial currently in appeal, or a denial that "fell through" last year. The next plan may have the same gap; a broker can flag it.
- An elder on Medicare or approaching 65. Marketplace, employer, and Medicare rules interact; the wrong move costs the household real money.
- A household member eligible for Medicaid or CHIP, especially children. Free or low-cost coverage may beat a marketplace plan dollar-for-dollar.
- COBRA running out, or an employer plan ending. The timeline for replacement coverage is short; missing the window means a gap year.
- A network so narrow that your current doctors aren't listed. "Out of network" is the most expensive word in any plan brochure.

## What success looks like in 24 hours

By Saturday morning, you have one notebook page with three short lists — routine, specialist, unexpected — and the current prescriptions by name. You have **not** opened a plan grid yet. The plan grid opens Monday, with last year's data in hand, not with last year's guess.

The right plan is the one that fits the year your family is about to have, not the cheapest premium in the email. The data is the homework; the comparison is the easy part.