CLEARly Beneficial Podcast

Ep. 2 Vinny Catalano: What You Need to Know for 2026 Open Enrollment

Vinny Catalano Season 1 Episode 2

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Your host of the CLEARly Beneficial podcast, Vinny Catalano, explores the critical decisions employees face during open enrollment for 2026 health coverage. He highlights that most employees spend only 9 minutes reviewing complex insurance materials, despite significant cost implications. The episode breaks down essential concepts including payer mix, out-of-pocket maximums, and the differences between HMO and PPO plans.

Vinny emphasizes the strategic advantages of high-deductible health plans paired with Health Savings Accounts, explaining how HSAs offer triple tax benefits and can serve as long-term investment vehicles. He stresses the importance of total cost of ownership analysis when comparing plans rather than focusing solely on premium costs.

The episode provides practical guidance on checking provider networks, verifying prescription drug formularies, and reviewing supplemental benefits. 

Disclaimer: This content is for educational purposes only. Please discuss your specific situation with your health benefits administrator or insurance provider for personalized guidance.

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Vinny Catalano: Hey everybody, this is Vinny Catalano, host of the Clearly Beneficial podcast, and today.

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Vinny Catalano: We're going to be talking about something that's going to affect everybody here in the next 6 weeks, and that is open enrollment. Well, most of you. I mean, I'd say…

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Vinny Catalano: 80-90% of American companies, small businesses, all renew their insurance policies for health insurance.

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Vinny Catalano: on January 1 for the 2026 plan year. So, uh, you'll be presented with information from your employer to take a look at, uh.

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Vinny Catalano: evaluating your choices, and uh, I thought it would be a good time to…

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Vinny Catalano: Just share some insights on decision-making that you want to consider as you go into this next cycle.

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Vinny Catalano: Um, first of all, you know, the days, I think, the open enrollment meeting are kind of over. I mean, some small group brokers still show up and do an open enrollment meeting for small business.

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Vinny Catalano: But for the most part, open enrollment meetings are, you know, at best, virtual, and at worst.

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Vinny Catalano: you know, your HR team, you know, shoots you a PDF and says, here, read this. Uh, the thing is, is that according to the MetLife study, and this has been a consistent thing for many, many years, uh, employees, you know, take.

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Vinny Catalano: 9 minutes to evaluate or even read the 75-page PDF that they're given, uh, to look for at open enrollment. And so.

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Vinny Catalano: Uh, you're making decisions now for all of your things in 2026.

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Vinny Catalano: And, uh, it takes… it probably is worthwhile for you to dig in a little deeper to make some positive and good decisions. This year in particular.

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Vinny Catalano: Um, health insurance rates have gone up, um, double digits. I mean, so employers are sitting there making decisions and saying, well, you know, do I pass some of that cost increase on to my employees? Do I eat it as an employer? Do I somehow share it? Um, I mean, so they're struggling with this, because in some cases, we've been seeing increases in the high double digits, 15, 20%, sometimes even more.

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Vinny Catalano: Um, rarity is the case where, you know, you're in the single digits, because, you know, hospital systems costs are going up, um, insurance companies are, you know, keeping their margins healthy.

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Vinny Catalano: And, uh, who gets caught with this, and that's you. One of the things, interesting things that drives the cost of health insurance is the fact that hospital systems, you know, they have this thing called payer mix, and you should know about this. It's something where, you know, coming into the door of a hospital, you have people who.

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Vinny Catalano: pay them different levels for the same procedures, right? So, you have someone coming in that may have Medicaid or Medi-Cal in California, Medicare for people over 65, and then commercial pay, and then, of course, there's people who don't have insurance at all who.

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Vinny Catalano: who, you know, don't pay. They're charity care. But when you look at the amount that gets billed from a hospital for those services, Medicaid, Medi-Cal pay them the least.

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Vinny Catalano: Medicare pays them the next least, but the people who pay the most are commercial payers. So, the brunt of increase in cost that a hospital.

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Vinny Catalano: has to, uh, fund for themselves generally gets.

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Vinny Catalano: put on employers. And by employers, that means via the insurance that employers pay. So this has been something that I've studied.

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Vinny Catalano: And, uh, have, you know, basically looked at over the last 20-something years, and on average, employer costs go up, you know, 9% a year. Now, this is going to be one of those outlier years where things are going to go up higher. So, what can you do as an individual when you're faced with your open enrollment materials? How do you make a decision? Do you stick with.

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Vinny Catalano: What you had this year, uh, do you look at the changes? Because you gotta be careful about how these changes are being presented to you. So, there could be changes in your coverage, so…

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Vinny Catalano: Uh, the co-pays might go up, the deductibles might go up.

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Vinny Catalano: You might be faced with the fact that the plan you had last year is no longer available.

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Vinny Catalano: So, you have to take a look at what the choices are and how those things, you know, will meet.

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Vinny Catalano: your needs and your family's needs. But there's a couple of basics that you really need to understand. You know, the two most important numbers, or actually the most important number in the health plan is.

00:06:29.000 --> 00:06:44.000
Vinny Catalano: this thing called the maximum out-of-pocket, out-of-pocket maximum, however you want to phrase it. This is the number that, if you were in a catastrophic situation, that you and your family would pay, and once you've met that number, the insurance company pays for.

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Vinny Catalano: your coverage 100% for the rest of the year. Now, most of us will never hit that number, okay?

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Vinny Catalano: Because, especially, you know, if you have nothing going on and you're reasonably healthy, which describes, you know, 85% of the population, you're never going to see the maximum amount of pocket. And I think in my lifetime.

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Vinny Catalano: me and my family have only hit that number one time, okay? But it's still an important number, because.

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Vinny Catalano: it can cost you to the point of thousands and thousands of dollars. So, a typical large group, if you work for a large employer, that, depending on the state you're at, it could be 50 or more employees, or 100 or more employees here in California.

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Vinny Catalano: You could have an out-of-pocket maximum for you as a single person of $4,000. Doesn't sound like a lot, right? Um, or for your family of $8,000.

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Vinny Catalano: But if you're in a small group plan for small business.

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Vinny Catalano: Those plans generally have higher out-of-pocket maximums, and those could be on the order of $8,000 or $7,000 for a single, and twice that for a family. So you could be facing an annual out-of-pocket maximum of, you know, um, you know, $14,000, $15,000, $16,000, which is very high. So add that, the out-of-pocket maximum.

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Vinny Catalano: To the amount of money coming out of your paycheck for you.

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Vinny Catalano: for your insurance, and that is your total cost of ownership for the year, potentially, in a worst-case scenario, okay?

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Vinny Catalano: So, that is probably one of the most key factors you have to play. Everything else.

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Vinny Catalano: Under that, which is the copay, the deductible.

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Vinny Catalano: The, um, coinsurance, all those things lead up to ultimately hitting that out-of-pocket maximum number.

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Vinny Catalano: So, you have to decide what's most important to you. Is it important to you to pay 40 bucks when you go see a doctor, or is it important for you to pay less for insurance? Because when you pay.

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Vinny Catalano: Take a plan that has a regular copay.

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Vinny Catalano: and a low deductible, you will pay more for insurance than the people who basically say, okay, I'm gonna take a consumer-directed, high-deductible plan and pay less for insurance, and then what you… then what they normally do, which is a great strategy, is pocket the difference.

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Vinny Catalano: Between what you would have paid for a rich plan, and what you're gonna pay for a consumer-directed plan, and put that in a health savings account.

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Vinny Catalano: Okay? A lot of people just say, okay, I'm just gonna save the money.

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Vinny Catalano: But the most important thing that someone can do in entering a high-deductible plan.

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Vinny Catalano: is… is participate in the HSA. Now, in some cases, your employer.

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Vinny Catalano: will contribute something to your HSA, and then it's up to you.

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Vinny Catalano: to put in… put in the max. I mean, for a family in 2000 and, um…

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Vinny Catalano: 25, the number was $8,550, you can put into an HSA, and um…

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Vinny Catalano: $95.50 if you're over 50 or 55 years old, as a catch-up contribution. So, it is an interesting vehicle.

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Vinny Catalano: To be able to consider, um, um…

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Vinny Catalano: putting money away, because number one, the money goes in, it's tax deductible, it's your money, whether your employer puts it in, or you put it in. There's no use-it-or-lose-it function of this.

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Vinny Catalano: And then you get to, depending on the HSA administrator, for example, I use a brokerage account, I can invest that money in mutual funds.

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Vinny Catalano: uh, exchange-traded funds, money markets, anything I want to invest in, okay?

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Vinny Catalano: And then when the money comes out for valuable healthcare expenses, or when you turn 65 to pay for Medicare, parts of Medicare, or long-term care for that matter, um…

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Vinny Catalano: that money comes out tax-free. So it's actually one of the few vehicles, the health savings account, that it benefits you tax-free going in.

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Vinny Catalano: And it benefits you tax-free going out.

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Vinny Catalano: So, uh, it's really something to take a look at. Now, what I do as a strategy is look at HSA and say, well, I'm just gonna put my… I just use it as another investment account, to be honest with you.

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Vinny Catalano: when I have a doctor visit or a pharmacy filling a prescription, I don't worry about my HSA. That money's just sitting there. The HSA is for a long-term strategy. Short-term strategy is to use just.

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Vinny Catalano: your credit card to pay for those out-of-pocket expenses, those low out-of-pocket expenses that you might have. So, that's something definitely, uh, to consider.

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Vinny Catalano: So, look at your total cost of ownership, look at the type of plan that you want to be in. So, a lot of you will get the choice of being offered an HMO, which is a narrow, focused plan, you have a narrow focus of doctors, you have a primary care physician.

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Vinny Catalano: That acts as your gatekeeper.

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Vinny Catalano: to refer you to other specialists in your network. So those plans tend to be a little more restrictive from a network perspective.

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Vinny Catalano: PPO plans, because of the fact that you now have the flexibility to go see the doctors that you choose to.

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Vinny Catalano: PPO plans tend to be a little more, um, expensive.

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Vinny Catalano: Especially when you're considering the same level of benefit. So, if you have a plan with a $40 copay, a $1,000 deductible, HMO versus PPO, that PPO will tend to be more expensive. Now, one of the things that's a bit of a misnomer is that, oh yeah, I can go to any doctor I want with a PPO, and well, that's true, but there's in-network docs, and there's out-of-network docs. So, when you go to an out-of-network doc.

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Vinny Catalano: The PPO almost operates as if it has a parallel health plan. The out-of-network component of it has a separate deductible, a separate out-of-pocket maximum.

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Vinny Catalano: Then, the in-network.

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Vinny Catalano: PPO. So it's something to keep your eye on, but it also gives you, you know, at the end of the day, if you want all that flexibility, if you feel.

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Vinny Catalano: that eventually you might want to go to the Mayo Clinic for something, having a PPO is definitely something to consider. You know, you should think about what's going on with you and your family, you know, when it comes down to the choice. Are you all healthy?

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Vinny Catalano: If you're all healthy, then being in a high-deductible plan coupled to an HSA makes sense. If you've got a lot going on.

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Vinny Catalano: It probably makes sense to take a look at what your total cost of ownership could be, again, premium and deductible, if you're anticipating a surgery, a pregnancy, any of those things in 2026.

00:12:59.000 --> 00:13:15.000
Vinny Catalano: all that should go into your analysis for what your total cost of ownership is. One thing also to make sure you're aware of is if, for example, there's some change in your plan, your employer said, okay, well, we're switching from X insurance company to Y insurance company, well.

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Vinny Catalano: things are gonna change, right? The doctor network might change a bit. The, um…

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Vinny Catalano: pharmacy formulary might change a bit. And that's super important, because if you're on a brand name drug in particular.

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Vinny Catalano: with insurance company, you know, X, that same drug may not be available in insurance company Y. So, a good rule of thumb is to make sure you fill that prescription.

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Vinny Catalano: For the drugs you're taking on the brand name right now, today, before the end of the year, so you have at least a 90-day supply going into 2026.

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Vinny Catalano: And, um, and then talk to your doctor about what is a better drug to switch to.

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Vinny Catalano: And drugs these days, and I'm gonna be doing other podcast episodes with people in the pharmacy industry, so stay tuned for those. But drugs are an interesting thing, because I know, example, my health plan.

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Vinny Catalano: Um, I take a couple of, um… I take a blood pressure drug, and I take a cholesterol drug, okay? When I took a look at the cost.

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Vinny Catalano: That it would cost me, through my health plan.

00:14:17.000 --> 00:14:20.000
Vinny Catalano: Via mail order, or for a 90-day supply.

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Vinny Catalano: The costs were very, very high relative to an.

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Vinny Catalano: Other out-of-network mail order choice.

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Vinny Catalano: and I'll just name names, Mark Cuban's Cost Plus Drugs. I pay one-third or less of the cost of these generic drugs through that vehicle versus what I would have paid through CVS in my own, um, uh, you know, health plan. So again, be a good comparison shopper. Think about the options you have to pay for the things.

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Vinny Catalano: Okay? So, checking your drug formulary, making sure the providers that you have are in the network if there are any changes, understanding the total cost is super important, making sure that the family members you have on the plan are the ones you want on the plan, and no, you cannot put your grandmother on the plan. You cannot put your cousins on the plan.

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Vinny Catalano: This is for you and your immediate family. So those are the people that are gonna be on the plan. Now, this opens up a whole other interesting conversation about, um…

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Vinny Catalano: Two spouses, both have employers, both have separate employer health plans, okay?

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Vinny Catalano: Um, a lot of thought goes into, um, I'll stay on my plan, you stay on your plan, we'll put the kids over here.

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Vinny Catalano: It makes sense to do an analysis.

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Vinny Catalano: On both plans, what the out-of-pocket monthly premium costs would be.

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Vinny Catalano: to put the whole family on one plan. And why I say this is that.

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Vinny Catalano: Say one plan… say this one spouse works for a large company with a low annual out-of-pocket maximum.

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Vinny Catalano: And the other spouse works for a small group that has small group plans.

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Vinny Catalano: Um, the person on the small group plans would probably have, um, a higher out-of-pocket maximum than the family plan. So, um, when you look at how these plans are structured, you know, I hate to use this term, but it's kind of like the car crash scenario.

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Vinny Catalano: Okay? Family, husband, wife, two kids get into a car crash, okay?

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Vinny Catalano: Husband is on his plan, kids are on his plan, spouse wife happens to be on the other plan. Okay? So, what does that mean? Well.

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Vinny Catalano: each… three of the people will be covered by one insurance, the other one will be covered by another. Um, that means you're building up separate deductible costs, you're building up separate out-of-pocket maximums, and therefore, it could.

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Vinny Catalano: Overall, cost the family a lot more in out-of-pocket costs, um, to have, uh, you know, both spouses on their own respective different plans.

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Vinny Catalano: So it really makes sense to do a little bit of a deep dive and understand the total cost of being on one plan together versus on separate plans, not just from a premium point of view, what's the least coming out of my paycheck.

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Vinny Catalano: But in the bigger picture, taking a look at co-pays, insurance, and out-of-pocket maximums and deductibles, because that becomes an entrance into the total cost of ownership.

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Vinny Catalano: Um, of course, you gotta make sure you're adding or dropping the right dependents, and I always tell people.

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Vinny Catalano: You know, no one really pays attention to this, but you have a baby, make sure that kid gets added to the plan within the first 30 days, not the 31st day. Insurance companies are pretty persnickety about that detail.

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Vinny Catalano: So, this is just a general refresher on open enrollment, um…

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Vinny Catalano: you're obviously going to have a lot of choices. I mean, literally, I wasn't joking when I say your HR people will send you a 75-page document, because they have to.

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Vinny Catalano: All the disclosures, all the plan outlines, I mean, and not just for medical. You're looking at, um, dental insurance, vision insurance, uh, long-term disability insurance.

00:18:05.000 --> 00:18:12.000
Vinny Catalano: short-term disability insurance, and all the supplemental benefits. They may be offering you pet insurance this year, which is a good deal.

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Vinny Catalano: Um, the one thing I want to really kind of point out to you as well is, is, uh, you know, people, you know, people discount… they look at all these benefits, and they go, great, I got medical, dental, vision, life insurance.

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Vinny Catalano: So there's a couple of points. First, life insurance, buying supplemental life insurance through your employer is the least costly way to.

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Vinny Catalano: bolster your life insurance for you and your family. That insurance company for your employer may have a guaranteed issue of a couple hundred thousand dollars that you could buy at a very low cost.

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Vinny Catalano: for you and your spouse to be insured by that insurance company. So life insurance, it's very cheap, and it's cheapest if you buy it through your employer, because there's no health questions under the guarantee issue number, and it's really no fuss, no muss.

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Vinny Catalano: But, the second most important insurance next to medical that you are offered if your employer offers it, and if they don't, you should ask them to offer it, and that's long-term disability, or I like to call income protection insurance. Income protection insurance is all about protecting your paycheck if, for whatever reason, you're disabled.

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Vinny Catalano: A lot of employers pay for it on your behalf, and you don't even know it's there, okay?

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Vinny Catalano: But a lot of employers may offer it to you on a voluntary basis, which means you need to… you could buy it yourself.

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Vinny Catalano: This is the thing that is amazing about long-term disability insurance. Let's say you're bringing home.

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Vinny Catalano: You know, $6,000 a month.

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Vinny Catalano: Um, long-term disability insurance will cover you up to 60% of that per month, and if the.

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Vinny Catalano: Premiums are taxed, that means you get a tax-free benefit until your normal retirement age.

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Vinny Catalano: So that could be… you can get a… basically, if you become fully disabled, you can get a tax-free paycheck.

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Vinny Catalano: up until age 65 or 67 or beyond. So, long-term disability insurance is something you should pay attention to. It's super important. If your employer is paying for it, amazing, give them a hug.

00:20:10.000 --> 00:20:18.000
Vinny Catalano: If they're not paying for it, and they offer it to you as a voluntary insurance product, you should consider it, because it's probably the least costly.

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Vinny Catalano: highest level of protection you would have in case something bad goes wrong. You're more likely to become disabled than you are to die.

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Vinny Catalano: So, it's definitely something for you to think about. So, I think that covers, you know, the high level of open enrollment. I mean, make the choices, make them on time, don't be that person that your employer is chasing around. You know, did you log into the system and do it? Because a lot of you are just going to log into a link.

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Vinny Catalano: You're gonna click, you're gonna go boom, boom, boom, boom, boom, and in many cases, your employer is gonna do a passive enrollment, right? If they haven't made any changes to the plans, the only thing they've changed is the rates.

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Vinny Catalano: They're gonna go, okay, well, you have this, this, this, and this. Do you want the same thing next year? Click here.

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Vinny Catalano: Take a minute, take a breath.

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Vinny Catalano: Take a look at the details. Look at what's there. Do you want to be on this plan that's going to cost you more out of your paycheck or less out of your paycheck? And then you get to fund that HSA. If you're young.

00:21:11.000 --> 00:21:14.000
Vinny Catalano: Okay, if you're Gen Z, if you're a millennial.

00:21:14.000 --> 00:21:18.000
Vinny Catalano: You will thank me when you're 60 years old.

00:21:18.000 --> 00:21:31.000
Vinny Catalano: that you funded that HSA for the last 25, 30 years. Because all of a sudden, you're going to be sitting there at age 60 with 200 grand in this HSA, because you're probably healthy and you're never going to use it.

00:21:31.000 --> 00:21:37.000
Vinny Catalano: And that is tax-free money that is available to you to pay for your healthcare into your.

00:21:37.000 --> 00:21:41.000
Vinny Catalano: Long-term retirement and, you know, going on in your life.

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Vinny Catalano: So, keep in mind that that HSA coupled to a high-deductible health plan is an incredibly smart strategy.

00:21:47.000 --> 00:21:56.000
Vinny Catalano: And, something to seriously consider. So, thanks for listening, here about open enrollment. good luck.

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Vinny Catalano: And, please share this podcast.

00:22:00.000 --> 00:22:07.000
Vinny Catalano: with anyone you'd like to share this knowledge with. I mean, the point of the podcast is to be educational, uplifting.

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Vinny Catalano: and being clearly beneficial. That's the point of the podcast, right? So it's gonna benefit you, it's gonna benefit your friends, and for the 20 minutes you just listened to.

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Vinny Catalano: to understand open enrollment, that's more information than your employer just gave you. So, um, best of luck, and we'll see you on the next episode, which will feature, uh, author Judith Kunish.

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Vinny Catalano: Talking about her book, Center of the Star, which is…

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Vinny Catalano: an amazing book, very well written, very accessible about the entire healthcare industry and how it works. And so, uh, excited to interview Judith.

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Vinny Catalano: And, uh, talk with her about her, uh, her new book. So, thanks again for listening.