Five Things to Check Before You Enroll This Open Enrollment

Open enrollment opened November 1, and the part that trips people up is not the paperwork. It is the order they do things in. Most people start with the premium, pick the lowest one they can live with, and find out in March what else was in the plan.

These are the five things I go through with people before anybody picks anything. Together they take an evening, not a weekend.

1. Your income estimate for next year, not last year

On the marketplace, what you pay depends on what you expect to earn in the coming year. For a household with two steady paychecks that is a quick answer. For self-employed people, 1099 contractors and anyone paid on commission, it is a real estimate with real consequences, because the marketplace reconciles the number you give against your actual income at tax time.

Two things follow from that. Guess low and you can owe at filing. And if you are well above the range where premium tax credits do anything, the marketplace is going to look expensive, which is the signal to price the other lanes before you commit to anything. The post on how income affects your premium covers the mechanics, and the above the subsidy line page covers the second case.

I am a licensed insurance agent, not a tax preparer. For the estimate itself, talk to whoever does your return.

2. Your doctors and your hospital, in the plan's own directory

This is the check people skip, and it is the one that does the most damage. Two plans can come from the same insurer and not share the same network.

So do not go by the brochure, and do not go by what was true last year. Pull the provider directory for the specific plan and the specific plan year, look up every doctor you actually see, then call the office and ask them directly. Front desks usually know before the directories do.

Pay attention to the hospital you would end up at in an emergency, not only your regular doctors. How networks work goes through what in network and out of network really mean once a bill shows up.

3. Your prescriptions against the formulary

Every plan carries a list of the drugs it covers and what tier each one sits on. A plan that looks fine on premium can put a medication you take every month on a tier that changes the math completely, or leave it off the list.

Write down what you take, including the dose, and check each one against that plan's formulary before you enroll. Reading a formulary covers how the tiers work and what your options are when something is not on the list.

4. All four numbers, not the premium by itself

The premium is what you pay to have the plan. The cost is what you pay when you use it. Those are different numbers, and plans that look good on one often look worse on the other.

Four numbers decide what coverage actually does: the premium, the deductible, the out-of-pocket maximum, and how the plan splits the bill in the gap between those last two. The four numbers breaks each one down. If you land on a high deductible plan, check whether it is HSA eligible while you are already in the documents, because that changes the picture: HSAs and high deductible plans.

The out-of-pocket maximum is the one I would not trade away for a lower premium. It is the number that decides what a bad year does to you.

5. Whether you have actually priced the private lane

Open enrollment is the marketplace's window. Medically underwritten private PPO plans do not run on that calendar, so they can be applied for in any month of the year. People still only think about coverage in November, which is exactly why this belongs on the list.

For a self-employed household that wants something stable to sit on for years, not just a plan for next year, this lane deserves a harder look than it usually gets.

Start with the part that works against it. A private plan can come in higher than a marketplace plan today, especially if a premium tax credit is still reaching you. What that buys is predictability. In what I have seen, premiums on the private side move much less from one year to the next, and the benefits rarely shift much either. You tend to know what you have, and you tend to still have it next year.

The marketplace is repriced every year. That is how it is built, and in practice the direction is rarely down. Put a climbing income next to that and the two can move together: the premium goes up, and whatever help you were getting can thin out at the same time. It is why a lot of self-employed people end up reassessing the whole thing every fall, and why it tends to get harder each year rather than easier.

The real gate is underwriting, and I am not going to talk around that either. Those plans ask health questions, and the answer can come back as a no. Nobody can promise you an approval, and I would not believe anyone who did. What I can tell you is that a decline on the private side does not close the marketplace to you, so looking costs you the time it takes to answer the questions.

There is a timing piece to that worth saying out loud. Underwriting looks at where your health is today, and health history mostly accumulates. On average, the version of you applying right now is the healthiest one that is ever going to apply. That is not a reason to rush, and it is not true for everybody, plenty of people improve on a given issue. But if the private lane is something you have been meaning to look at for a couple of years, it is the part of the picture that argues against leaving it on the someday pile.

Three lanes, every time: the marketplace, a private underwritten plan, and an employer plan if anyone in the household has access to one. How to compare plans is the longer version of that comparison.

What to have in front of you

Your income estimate for the coming year. A number you can defend, not a hopeful one.

Your doctors and your hospital. Names, not "my regular place."

Your prescriptions, with doses. All of them, including the ones you forget because they are routine.

Your current plan's renewal notice. The letter nobody opens. It tells you what your plan is becoming next year, which is often not what it is now.

That last one matters more than people expect. A plan auto-renewing into something you have not read is still a decision. It is just one that somebody else made for you.

If a term in the paperwork is doing work you cannot follow, the glossary exists for exactly that.

Frequently asked questions

Where to start

Work the list in order. The income estimate tells you which lane you are shopping in. The network and the formulary tell you whether a plan covers your actual life. The four numbers tell you what it costs on the day you need it.

Then compare on total exposure rather than on premium, and do it while the window is open rather than in the last week of it.

If you want help with that, it is the whole job. We go through your five, compare what is available across the lanes, and if the plan you already have is the best thing on the table I will tell you that too.

DC Insurance is an independent health insurance agency serving Middle Tennessee. This is general information about how coverage works, not advice about your particular situation. Coverage availability and eligibility vary by individual circumstances.