Questions you aren’t asking (but should) during open enrollment

Nobody enjoys open enrollment, but health insurance is an important part of your financial health. Whether you get insurance through your employer or through the Affordable Care Act marketplace, it’s critical to ask the right questions before selecting a health plan for 2024.

“Open enrollment is a great time to do a personal health audit,” says Charlene Rhinehart, a personal finance editor at the drug savings website GoodRx. “Understanding your current and anticipated health care needs will help you decide which plan is the best fit.”

Here’s how to evaluate your options.

Do your doctors participate in the network?

The networks of plans change from year to year. If you have a favorite doctor or specialist, make sure they are still in the network of the 2024 plan you are considering.

You should also consider whether you want the option to go out of network, which is usually available in a preferred provider organization, or PPO, plan but will cost more. HMOs, or health maintenance organizations, are less expensive but lack out-of-network flexibility.

Are your prescription medications covered?

If you take prescription medications, review plan formularies to ensure that you understand how your medications will be covered in 2024. Even if you stay with the same plan year after year, your drug coverage may change.

“Even if you were in an Aetna plan before, and you say, ‘Well, I’ll stay with Aetna again,’ you still want to look and make sure the medication you’re taking is still on the formulary,” says Abbie Leibowitz, chief medical officer and co-founder of Health Advocate, which provides integrated health advocacy and health benefits programs.

What are your out-of-pocket expenses?

Every plan has fixed costs, such as monthly premiums, as well as care costs, which include the deductible and any copays or coinsurance. When comparing plans, you must estimate how much health care you will use in the coming year.

On the one hand, there are the costs you’d incur if you only used the plan for preventive care. If you use health care frequently, however, you have a maximum amount you can pay in each plan. These scenarios are easily comparable.

However, there is a squishy middle ground in which the best plan for you is determined by the amount and type of care you will require next year.

“The tricky part is that we never really know how much we’re going to spend in a given year if we’re in the middle,” says Adam Rosenfeld, president of employee benefits firm Rubicon Benefits and a health care benefits expert. He recommends looking at your current claims data and imagining that the following year will be the same. Which plan would be better for you?

“At this point,” Rosenfeld says, “it’s the best predictive modeling you can do.”

Do you need a high-deductible plan?

In 2024, a high-deductible health plan, or HDHP, is one with a deductible of at least $1,600 for individual coverage or $3,200 for family coverage, and out-of-pocket maximums of no more than $8,050 or $16,100, respectively. HDHPs typically have lower premiums, and employers may contribute to a health savings account, or HSA, to help cover the deductible.

An HDHP can be a good fit for people in a variety of health situations, as long as they’re willing to pay the deductible if they need medical attention.

“The question is, ‘Can you afford it?'” says Adria Gross, an insurance broker, consultant, and the founder of MedWise Insurance Advocacy, which assists clients and attorneys with medical claims. If you’re in good health, Gross recommends the HDHP. However, in the event of a serious accident, you should ensure that you have the funds to cover the entire deductible.

Is it possible to stack benefits?

Your employer may provide voluntary benefits that can help cover costs that your insurance does not cover. Aflac policies, for example, can help pay for expenses if you are in an accident or are diagnosed with cancer.

You may discover that a high-deductible health plan plus a supplemental plan to help you cover your deductible can be obtained for less than the cost of a traditional health plan. “It can be a lot less than moving to the next tier where the deductible is lower,” Leibowitz said.

Do you require special care?

Some insurance plans cover procedures like weight loss surgery or infertility treatments, but others don’t, and the exclusion can be significant if it’s a procedure you’re considering. You may discover that one insurance company covers a particular surgery or test while another considers it experimental and not medically necessary.

“I call them the fringes,” says Leibowitz. “They’re beyond the typical medical and surgery coverage.” He claims that the focus is narrow, but the coverage is significant.

The underlying message, he says, is that just because it appears to be the same plan from the same company as last year, don’t assume it hasn’t changed in ways that are important to you. “Network, formulary, benefits,” says Leibowitz, “you have to do your homework.”