As we head into fall, it’s time for changing leaves, pumpkin-spiced everything, and holiday prep. But there’s one more seasonal item that should be high on your list: open enrollment. This year, shopping around for health insurance is more crucial than ever, given rising healthcare costs, changes to government policies, and an increase in available plans.
Unfortunately, it’s easy to make costly mistakes during open enrollment. According to a survey from GEHA, a not-for-profit provider of health benefits for federal employees, 46% of Americans said they chose the most expensive health insurance available to them because they assume it’s the best coverage available. (Hint: that’s not necessarily true!) Simultaneously, 60% of people said their current insurance provides more coverage than they really need. In other words, as you’re choosing coverage for 2025, and it’s imperative that you shop around rather than just auto-renewing the policy you had last year.
We know the process of choosing a plan can be incredibly confusing, which is why we decided to put together a 101 guide on shopping for 2025 health insurance coverage during open enrollment 2024.
Open Enrollment Dates: Mark Your Calendar
Whether you’re purchasing health insurance through the exchanges or from your employer, the open enrollment windows vary slightly depending on the type of coverage:
- For those using the HealthCare.gov marketplace, open enrollment starts on November 1 and ends on December 15. (This is to ensure you have coverage on Jan. 1. But you can a,so enroll as late as Jan. 15, 2025 if you’re willing to have coverage start on Feb. 1)
- Medicare’s open enrollment runs from October 15 to December 7.
- Employer-provided insurance plans follow different timelines, so check with your benefits department. For instance, federal employees will have open enrollment from November 11 to December 9.
Some Considerations Are Universal
Choosing a health insurance plan means striking a balance between the care you need and the price you pay. A policy for which you pay high monthly premiums will generally provide a richer menu of benefits, including fully covered preventive care, with a lower deductible (the amount you have to pay out-of-pocket before the insurance company steps in to pay). A policy with lower premiums will generally come with reduced benefits and a higher deductible.
Three universal considerations should be the provider network you have access to, prescription medication you’re currently taking, and if you’re anticipating any life changes next year — like having a baby. Before choosing a plan, check to be sure that the doctors you want and the hospital you’re most likely to go to in an emergency are in-network with your plan. Do the same with medications you’ll need for any chronic conditions.
It’s also helpful to understand the basic differences among plan types:
- A Health Maintenance Organization or HMO (and almost all plans on the healthcare.gov marketplace are now HMOs) provides a network of doctors and hospitals that you can access for care that the insurer will pay (or help pay) for. If you see an out-of-network provider, your claims will not be covered. With an HMO you’ll choose a primary care provider (PCP) and will typically need a referral to see a specialist.
- A Preferred Provider Organization or PPO provides more freedom. You may or may not need to choose a PCP, but you typically don’t need referrals to see specialists. Also, if you see an out-of-network provider, your services will be covered, but you will likely pay a higher portion of the charge. PPOs are more expensive than HMOs.
- A High Deductible Health Plan (HDHP) can work with an HMO or PPO, but generally comes with greater out-of-pocket costs before benefits kick in. Because of that, premiums are typically lower. If your deductible is $1,650 or greater for a single person in 2025 or $3,300 for a family (with out-of-pocket expenses capped at $8,300 for singles, $16,600 for families) you will be eligible to open a Health Savings Account (HSA) that enables you to pay for medical expenses with pre-tax dollars. This effectively provides a 25-30% discount (ish) on all your medical care. Oftentimes, HDHPs through an employer offer an automatic contribution to your HSA — which can make these plans very appealing. But a word of caution: To get the most out of a HDHP, “you need to be relatively healthy and have disposable income where you could afford to pay your full deductible if you do get hit by an unexpected health event, explains Sabrina Corlette, a research professor, founder, and co-director of the Center on Health Insurance Reforms (CHIR) at Georgetown University. “If you’re the kind of person who would set aside money into your HSA every month and you’ll be disciplined, then a HDHP with an HSA can be a really good value.”
If You Get Health Insurance Through Your Employer…
First, pay particular attention to your specific open enrollment dates — keep an eye out for correspondence from your benefits departments rather than just automatically deleting yet another HR email. Then compare the plans you’re offered.
“Even if you are planning to stick with the same plan choice you made last year, make sure you know what changes have been made to that coverage,” explains Kaye Pestaina, director of the Program on Patient and Consumer Protection at KFF. “Is the prescription drug you are taking still on the plan’s formulary and at the same cost? Are there new or increased charges for care compared to last year—for example, an increased charge to use the emergency room? A new change that limits the pharmacy where you can get prescription drugs? If that is the case, you may want to look at other coverage options that your employer makes available.”
Also, be particularly alert for so-called “narrow network” plans that limit your choice of providers — they may be more common in 2025. Pestaina says you’ll want to review your plan’s Summary of Benefits and Coverage (SBC) and the plan’s provider directory to see exactly what each plan offers. The SBC document is required by law and should help you compare options across several important factors. “Plans are also required to have up-to-date directories of in-network providers,” Pestaina explains. “You may want to contact your providers directly to make sure they are in-network if you are looking to switch to a new health benefit option.”
If You’re Shopping on the Open Market …
On the individual market, you can expect more coverage options this year. For this reason alone, you shouldn’t assume the policy you bought last year is the right one for you this year.
You also shouldn’t assume you’re getting an accurate subsidy on coverage you buy on the exchange based on last year’s information. Go onto the exchange and update your income and other information. Your subsidy amount is based on the second-lowest-cost silver plan, and that plan may have changed this year. If you don’t update your income and other information on the exchange, you could miss out on savings or end up owing more out of pocket. Be sure to compare SBCs to understand how different plans stack up. (Note: Enhanced subsidies that were required by the Inflation Reduction Act will continue for 2025, but this will be the last year for them, unless reauthorized.)
Additionally, be mindful of the differences between shopping on healthcare.gov or an affiliated state exchange and using a private marketplace. On healthcare.gov, you’ll only find ACA-compliant plans that cover essential health benefits and offer subsidies based on income. Private marketplaces, however, may offer other types of insurance, like short-term plans or illness-specific policies, which may not provide the same level of coverage or financial assistance. Thankfully, Pestaina notes that this year, federal law will require that these short-term plans and others will have to prominently state in written materials that these are not comprehensive health coverage, but it’s always good to triple-check the specifics.
What to Watch for in the Coming Year
Starting in 2025, plans purchased via healthcare.gov are required to show the government that they meet specific standards for appointment wait times for in-network providers for primary care and behavioral health providers, Pestaina says. The hope is that consumers can get more timely appointments when trying to access in-network care.
“It’s not clear what insurers in the federal marketplace have done to prepare for the new appointment wait time rules, but there will be efforts to see whether there are differences in actual wait time for patients seeking specific types of care,” Pestaina says.
At A Glance: Questions To Ask As You Make Your Decision
Still feeling overwhelmed? Don’t be. Here’s a quick list of the questions you should ask as you weigh your options for 2025:
- Provider networks: Will your preferred doctors and hospitals be included?
- Prescription medications: Will your current medications be covered, especially if you have chronic conditions?
- Life events: Do you anticipate major life events, such as getting married, that may change your healthcare needs?
- Costs other than your monthly premium: How much will you have to spend out of pocket (your deductible) before regular copayments or coinsurance kick in? Is there a separate deductible for prescription drugs?
- Know your MOOP The Maximum Out-of-Pocket (MOOP) is the most you’ll have to pay for healthcare services in a year. You should know this number, because once you hit your MOOP limit, your health insurance will kick in to cover 100% of the costs for the rest of the year.
- Plan administrative hurdles: Will you have to get prior authorization before you can access a medicine or service that you’re currently using? What does that authorization require?
READ MORE:
- HerMoney Podcast: Navigating The Healthcare System And Being Your Own Advocate
- What Kind Of Life Insurance Do You Need?
- How To Get Mental Healthcare Without Breaking The Bank
SUBSCRIBE: If you’re not subscribed to the HerMoney podcast, you’re missing out on juicy tidbits from some of the most accomplished women in the world. Join us!