Health
An Open Enrollment Checklist That Takes One Evening
Most people re-enroll in the same plan because the window closed before they got around to comparing. Here is a version of the job that fits in one sitting.
Health plans change every year even when you do not. Networks shrink, drug formularies get reshuffled, deductibles drift upward, and the subsidy you qualify for moves with your income and with what the benchmark plan in your area costs. Automatic re-enrollment protects you from a coverage gap. It does not protect you from paying more than you need to.
Know your dates
For plans bought through the Marketplace, open enrollment typically runs from the start of November into mid-January, with coverage beginning January 1 for people who enroll by roughly mid-December. Employer plans run their own window, usually in the fall. Medicare has separate periods entirely. Check the exact dates for your situation each year, because they have shifted before, and note that some states run their own exchanges with longer windows.
Outside those windows you generally need a qualifying life event, such as marriage, birth or adoption, a move, or loss of other coverage, to enroll. That opens a special enrollment period of limited length, so act quickly if one applies to you.
Step one: gather four things
- Your best estimate of next year's household income, since Marketplace subsidies are based on projected income, not last year's
- A list of every prescription anyone in the household takes, with dosage
- A list of the doctors and facilities you want to keep
- Anything you know is coming next year: a planned surgery, a pregnancy, ongoing therapy, a child aging onto or off the plan
Step two: check the network before the price
Do not trust a provider directory alone. Directories are frequently out of date. Call each doctor's billing office and ask whether they are in network for the specific plan, by its full name, for next year. "We take that insurance" is not the same answer as "we are in network for that plan." The distinction is the difference between a copay and a bill.
Pay attention to the plan type. An HMO usually requires you to stay in network and get referrals. A PPO costs more but covers out-of-network care partially. An EPO sits in between, with no referrals but no out-of-network coverage. If a specialist you rely on is outside the network, an HMO is a hard no regardless of price.
Step three: check the drug formulary
Search each medication in each plan's formulary and note the tier. A drug that was tier two this year can be tier four next year, or removed entirely, which can change your annual cost by thousands. Also look for prior authorization and step therapy requirements, which mean the plan will require paperwork or a trial of a cheaper drug before covering yours.
Step four: compare total annual cost, not premium
Build a simple total for each candidate plan: twelve months of premium after any subsidy, plus your realistic expected cost sharing. Run it twice, once for a normal year and once for a bad year where you hit the out-of-pocket maximum. The plan that wins the normal year is not always the one you want if a bad year would be unaffordable.
One item is easy to miss: if your income puts you below roughly two hundred fifty percent of the federal poverty level, cost-sharing reductions can dramatically lower a silver plan's deductible and out-of-pocket maximum, but only on silver. In that income band, comparing a bronze premium to a silver premium without accounting for the reductions is comparing the wrong numbers.
Step five: report your income honestly
Marketplace subsidies are advance payments based on your estimate, and they get reconciled on your tax return. Underestimate your income and you may owe money back. Overestimate and you overpay all year and get it back later. If your income changes mid-year, update the Marketplace rather than waiting.
Free help exists
Every state has trained Navigators and certified assisters who help with Marketplace enrollment at no cost to you. Local nonprofits, community health centers, and libraries often host them. If your situation is complicated, that hour is well spent.