Families often face several choices for a health plan, and the choices can change annually during an open enrollment period. Employers (and the ACA) offer access to multiple health plans. Often, employer plans are part of a ‘cafeteria’ of benefits, and two employed spouses likely have different health plans with different options.

It requires a review, comparison, and evaluation, both annually and when a spouse changes employer. If there are two spouses, they generally choose the family plan with the best coverage for their family situation and budget each year. But they don’t have to. If one employer offers an HRA or FSA while the other offers an HSA, you may want to keep both.

1. A Health Reimbursement Account (HRA) is employer funded, the amount isn’t limited, it can be used with an ACA plan, and it can pay plan premiums.

2. A Flexible Spending Account (FSA) is an account you (or your employer) can put money in, the amount is limited, it cannot be used with an ACA plan, it cannot pay plan premiums, but it is not taxable income. It can pay deductible, co-pay and non-covered medical expenses.

You may choose to pay medical out-of-pocket costs from the HRA or FSA, then concentrate savings in the HSA to reach the higher family limit of the HSA. Beyond a health plan, employers offer very different benefits. Sometimes a benefit, like dental or wellness is linked to a specific health plan. Other benefits, like gym memberships and education may be limited to the employee. Still others like short and long-term disability or life insurance might be portable.

Smaller employers often integrate the ACA market with their benefits. The ACA is also an extension of Medicaid, another public plan to make medical care affordable for low-income people. One Medicaid program, ESI Premium Assistance, helps with premium payment assistance when an employer’s health program is more cost effective than Medicaid by itself. But the program varies by state, and not all states offer it.