Open enrollment strategy: what to actually do during the window

Health insurance open enrollment happens annually, in two main windows:

• ACA marketplace and most employer plans: November - January (state-specific deadlines)
• Medicare: October 15 - December 7

Most people don’t seriously evaluate their plan each year. They stay on the same plan, accept whatever changes the carrier makes, and pay whatever new premium results. This is usually a financial mistake.

Plans change year to year. So do your circumstances. So does the relative competitiveness of different plans. Open enrollment is the one window where you can re-optimize.

What changes year to year

Carriers change:

• Premiums (almost always go up; sometimes plans become competitive that weren’t before)
• Networks (in/out of network providers shift)
• Formularies (which drugs are covered and at what tier)
• Plan design (deductibles, OOP max, copays, coinsurance percentages)
• Available plans (new plans entered the market, existing plans discontinued)

You change:

• Income (affects subsidy eligibility on the marketplace)
• Family composition (marriage, divorce, kids, dependents)
• Anticipated medical needs (planned procedures, pregnancy, new diagnosis)
• Prescription needs (new medications, dropped medications)
• Provider preferences (new doctor, changed specialist)

The audit process

Each year, before open enrollment closes:

1. Calculate last year’s actual cost.

Pull statements. Total:

• Premiums paid
• Deductible paid
• Copays paid
• Coinsurance paid
• Out-of-network costs
• Prescription costs

That’s your true cost on your current plan for the year. Most people guess wrong about this — actual cost is often 30-50% higher than people remember.

2. List anticipated next-year medical needs.

• Regular prescriptions (and likely new ones)
• Anticipated procedures or surgeries
• Pregnancy or fertility plans
• Therapy or mental health needs
• Chronic conditions requiring ongoing care

3. Pull next year’s plan options.

For employer plans: HR provides the menu. For ACA marketplace: HealthCare.gov (or state marketplace) lists all available plans. For Medicare: Medicare.gov plan finder.

4. Run scenarios on each option.

For each plan, calculate:

• Annual premium
• Expected deductible spending based on anticipated needs
• Expected copay/coinsurance spending
• Out-of-pocket max in worst-case scenario

Compare total expected cost AND worst-case cost across plans.

5. Check networks and formularies.

For each candidate plan:

• Are your current doctors in-network?
• Are your current medications covered?
• What tier are your medications (affects copay)?

A cheaper plan that puts your specialist out-of-network or moves your medication to specialty tier may cost more in practice.

Common open enrollment moves

1. Switch from PPO to HDHP if you’re healthy.

If you spent under $2,000 on medical care last year and you’re young/healthy, an HDHP + HSA combination is often dramatically cheaper. The HSA also doubles as a retirement vehicle.

2. Switch from HDHP to PPO if you’re getting pregnant or have a new diagnosis.

Anticipated high medical use makes PPO or HMO with lower OOP max better than HDHP.

3. Verify your subsidy on the marketplace.

If you’re on a marketplace plan, the premium tax credit recalculates based on income. Update your income estimate accurately — overestimating reduces your subsidy; underestimating means you’ll owe at tax time.

4. Switch carriers if your provider network has changed.

Carriers regularly add and drop providers. If your doctor or hospital was dropped from your plan’s network, switching may be necessary.

5. Reassess Medicare Advantage every year.

MA plans change extras (dental, vision, OTC) and networks annually. The “best” MA plan last year may not be this year.

6. Switch Part D plans if your prescriptions changed.

Part D formularies and tiers change. A drug that was tier 2 last year may be tier 4 this year, dramatically affecting your costs.

Mistakes to avoid

1. Auto-enrolling without review.

Most plans auto-enroll you in the same plan (or a successor plan). Letting this happen without review costs people thousands every year.

2. Choosing on premium alone.

The cheapest premium plan is often more expensive in total once you factor in deductibles, copays, and out-of-network costs.

3. Missing the deadline.

Most open enrollment windows are firm. Miss it and you’re stuck for a year (with limited exceptions for “qualifying life events”). Calendar the deadline.

4. Not coordinating across household members.

In families with multiple workers, evaluating whether each person should be on their own employer plan or one shared plan can produce significant savings.

5. Forgetting HSA / FSA contribution decisions.

Open enrollment is when you set your HSA or FSA contribution for the year. Don’t default to zero or last year’s amount without thinking.

Special situations

Job change mid-year. Loss of employer coverage is a “qualifying event” allowing you to enroll outside open enrollment. Options: COBRA, marketplace plan with subsidy, spouse’s plan.

Marriage or divorce. Qualifying event for marketplace enrollment changes. Coordinate plans across spouses to optimize.

New baby. Qualifying event. Add the child to the plan within 30-60 days (varies by plan).

Moving to a new state. Qualifying event for marketplace. Network and plan availability changes.

What to do this open enrollment

1. Calendar the deadline — both for your initial enrollment and any changes you might want to make
2. Run your actual cost calculation for the past year
3. List your anticipated next-year needs
4. Compare at least 3 plan options — don’t just default to last year’s plan
5. Verify networks and formularies for finalists
6. Set HSA/FSA contributions intentionally
7. Make the change before the deadline

A few hours of work during open enrollment can save thousands. Most people skip it. Don’t.