Open enrollment: what you need to know

What is open enrollment?

Open enrollment is a time each year when you can review your health insurance and, depending on your type of coverage, enroll in a plan or make changes for the coming year.

Even if you are happy with your current coverage, it is important to review it every year. Your plan may change, including:

• How much you pay out of pocket for things like your premium, deductible, copays, or coinsurance
• Which doctors, specialists, and hospitals are in your plan’s network
• Which pharmacies you can use
• Which medications your plan covers (also known as the formulary or drug list)
• How much you pay for your medications
• Which services and benefits are included
• What steps or approvals you need before receiving certain medications or services

Plus, your healthcare needs may have changed since you picked your plan last year. For instance, you might have started a new medication, changed or added a new doctor, or needed different healthcare services or treatments.

Even if your plan currently covers your healthcare needs, do not assume coverage or cost will stay the same next year. Be sure to read all notices from your health plan and compare your coverage with the options available for the coming year.

Before you start

Before you review your coverage or start shopping for new options, gather the following details so you have a clear picture of your healthcare needs and costs:

• Your current insurance information
• A list of your medications, including the name, dose, and how often you take each one
• The names of your doctors and specialists
• Your preferred pharmacy
• Healthcare services or treatments you expect to need in the coming year
• What you currently pay for coverage, healthcare services, and prescriptions

If you plan to add other family members or dependents to your plan, you will also want to have their information handy.

Having all this information in one place makes it easier to see if a new plan covers the care and medications you need and understand what you may have to pay out-of-pocket.

PAF’s Understanding Your Health Insurance Policy Documents resource explains how to read key health insurance documents, including your member or subscriber ID card, Summary of Benefits and Coverage, and Summary Plan Description, and what you can expect to find in your plan’s policy language.

Your plan choices may change

Not every plan is available everywhere or every year

The health insurance plans available to you largely depend on where you live. Some plans may only be offered in certain states, counties, or service areas. Plan options can also change from year to year, so a plan that was available to you last year may:

• No longer be offered
• No longer be available where you live
• Be replaced by a different plan
• Have changed its provider or pharmacy network
• Have changed its prescription coverage or benefits

Important: Do not assume your current plan – or a plan you have heard about – is available to you for the upcoming year.

Before selecting or renewing a plan:

• Confirm that the plan will be offered in your area
• Make sure your doctors, specialists, and hospitals are in the plan’s network. If a provider is out-of-network, you may still be able to see them, but your out-of-pocket costs will likely be higher.
• Confirm that your preferred pharmacy participates in the plan or if a change will be required
• Check whether your medications are covered and what they will cost
• Review the plan’s premium, deductible and other out-of-pocket costs
• Compare all available choices before enrolling

And remember, a low monthly premium (the cost you pay to keep your coverage) does not always mean a plan is cheaper. Sometimes a low premium means you have to pay more out of pocket when you go to the doctor or buy medicine. Consider both what you pay to keep the coverage and what you may pay when you get care.

Choosing your coverage

Read our guides to choosing your health insurance coverage for the coming year. Learn what to review and consider during open enrollment for:

Do you get your health insurance through your job or your spouse’s job?

Many companies offer health insurance as an employee benefit. Here are some tips to figure out how to make the best choice for you and your family:

• How Plan Differences Can Affect Your Healthcare
• Choosing the Right Health Insurance for You
• Important Questions to Ask When Choosing a Plan

Do you currently not have insurance, but want to sign up during open enrollment?

PAF’s How Do I Get Health Insurance? resource explains common types of health insurance and where you may be able to get coverage.

Keep your coverage

Once you have signed up for a plan during open enrollment, remember you still have to pay for your current plan until your new plan kicks in. When your new plan begins, it’s important you know what you have to pay to keep your coverage.

Know what you need to pay to keep your coverage:

• Premium: The amount you may need to pay regularly to keep your health coverage. This is different from the costs you pay when you receive care. 
• Deductible: The amount you may need to pay for covered care before your plan begins paying for certain services. 
• Copay: A set amount you pay for a covered service or prescription. 
• Coinsurance: A percentage of the cost you pay for a covered service or prescription. 

Learn what these and other insurance words mean in PAF’s The Language of Insurance.

How to keep your health coverage active

If your coverage requires a premium:

• Know how much you owe
• Know when the payment is due
• Know how to make your payment
• Make sure automatic payments are updated if your plan or premium changes
• Read notices from your health plan about missed or late payments

Important: Choosing or renewing a health plan does not always mean your coverage is fully taken care of. If you owe a premium, you will need to keep paying it to keep your coverage active. Missing required premium payments can interrupt or end your coverage.

If you miss a payment

Act as soon as possible:

• Read the notice from your health plan.
• Check how much you owe and the payment deadline.
• Contact your health plan using the number on your insurance card.
• Ask whether your coverage is still active.
• Ask what you must do to prevent your coverage from ending or to restore it.
• Write down whom you spoke with, the date, and any confirmation number.

If you are having trouble paying, contact your health plan before the payment deadline. Ask whether there are payment options or other steps that may help you keep your coverage

If your coverage has ended or may be canceled, review PAF’s Health Plan Cancellations and What to Do Next.

Get help

I don’t understand my insurance

Use PAF’s The Language of Insurance to learn the meaning of common health insurance words.

I’m not sure what coverage options I have

Read PAF’s How Do I Get Health Insurance? for an overview of common ways to get health coverage.

I need to learn about Medicare

Visit PAF’s Learn About Medicare to learn about Medicare Parts A, B, C and D, enrollment, costs, appeals and other Medicare topics.

I need one-on-one help with an insurance problem

Learn about PAF Case Management, which may help eligible patients understand insurance options, apply for coverage and address healthcare access or affordability challenges. You can also call PAF at 800-532-5274, Monday through Friday, from 8:30 a.m. to 5:00 p.m. Eastern Time.

I need help paying for care

Charitable patient assistance programs, like Patient Advocate Foundation’s TotalAssist, provide grants to eligible people with serious or chronic conditions.

Depending on the fund, help may be available for:

• Medication copays
• Coinsurance
• Deductibles
• Health insurance premiums and
• Certain treatment-related costs

Check the fund for your condition to learn what it covers and whether you may qualify.

What about assistance from a drug manufacturer?

Manufacturers do not provide financial assistance to people with federal insurance, including Medicare. Manufacturer patient assistance programs (PAPs) operate outside of the Medicare Part D benefit, so medications provided through a PAP cannot be included in the Medicare Prescription Payment Plan.

If you have Medicare, explore other sources of help first, such as the federal Extra Help program or charitable assistance programs offered by organizations like the Patient Advocate Foundation.

Other ways to lower out-of-pocket prescription costs

If you’re worried about the cost of your prescription medications, help may be available. Different options and resources are available to help reduce out-of-pocket prescription medication costs. Explore our guide to ways you can lower your prescription costs.

Financial assistance for your prescription medications

Financial assistance options are available from multiple sources: the federal government, state government, nonprofit programs, and the private sector, which usually includes for-profit companies. Read our guide to patient financial assistance.