Open Enrollment: Choose the Best Health Plan for Your Needs

There’s a great deal of turmoil and uncertainty about health insurance right now due to the congressional stalemate and government shutdown that is largely about proposed cuts in Medicaid and whether subsidies for the Affordable Care Act (ACA) will be continued. Millions of Americans may lose their health insurance due to new restrictions in eligibility rules or unaffordable increases in premiums. It is unclear when or how this stalemate will be resolved.

Despite this uncertainty, October through early December is the only time of year (barring changes in life circumstances like births, deaths, marriage, or moving to a different area that is not served by their current insurance), when Americans can choose to change to a different health insurance plan. This is known as the open enrollment period, and it applies to Employer/Group Health Insurance Plans, the Affordable Care Act and Medicare. Some may also want to determine whether they are now eligible for Medicaid.

Your choice of health insurance plans can have a major impact on your quality of life or even the length of your life so it’s important to pay attention.

This article lists the open enrollment deadlines, explains the reasons it might be advisable to look at your options, and what types of options are available.

Open Enrollment Period for Different Types of Health Plans

Plan Type	Typical Open/Annual Enrollment Period	Special Notes
Employer-sponsored	Usually Fall (Oct/Nov) for coverage starting Jan 1	Employer sets exact dates; changes generally only for life events otherwise
ACA Marketplace	Nov 1 → Jan 15 (many states)	Enroll by Dec 15 for Jan 1 start; after that start Feb 1; Special Enrollment Period if life event
Medicare (for existing enrollees)	Oct 15 → Dec 7	If you already have a Medicare Advantage Plan,  can make changes Jan 1–Mar 31
Medicare Initial Enrollment (new)	3 mo before → birthday month → 3 mo after	Missing it may lead to penalty

Why You Should Consider Changing Your Health Plan

1. Your Health or Life Situation Has Changed

Your current plan may no longer fit your needs if you’ve experienced:

• New medical diagnoses or chronic conditions requiring specialists, therapies, or ongoing medications.

• Major life events such as marriage, divorce, having a baby, or a child turning 26 (aging out of a parent’s plan).

• Relocation — moving to a new ZIP code, state, or county can change your provider network or coverage area.

Even small changes in health can make a big difference in how much care you use and how important low deductibles, drug coverage, or telehealth benefits become.

2. Premiums, Deductibles, or Out-of-Pocket Costs Are Rising

Each year, insurance companies adjust:

• Monthly premiums

• Deductibles and copays

• Maximum out-of-pocket limits

A plan that was affordable last year might become too expensive this year. Comparing options during open enrollment can reveal lower-cost plans with similar or better benefits, especially if you qualify for premium tax credits through the ACA Marketplace.

3. Your Preferred Doctors or Hospitals Are No Longer In-Network

Networks change frequently, usually because healthcare providers opt out. If your doctor, therapist, or hospital is no longer covered in-network, switching plans can save you hundreds or thousands of dollars per year.

Always confirm provider networks and prescription formularies when reviewing plan options. Ask your doctor’s office if they are still participating, rather than rely on what is reported by your insurance company. Sometimes insurance companies still list providers as in-network even after they drop out.

4. Your Prescription Needs Have Changed

If you’ve started new medications or found your current prescriptions aren’t fully covered or have been dropped from coverage, another plan may:

• Cover your medications at a lower copay

• Include your pharmacy in-network

• Offer mail-order or 90-day refills for convenience and possibly savings

⚙️ 5. You Qualify for Better Coverage or Savings

Many Americans miss out on savings because they don’t re-check their eligibility each year:

• Marketplace subsidies and cost-sharing reductions can change if your income shifts.

• Medicaid or CHIP eligibility may open up if your financial situation changes.

• Employer benefits (like FSAs, HSAs, or wellness programs) might now include incentives or new coverage options.

6. Plans Add (or Drop) Benefits Each Year

Insurance plans are not static — each year, carriers update:

• Covered services (e.g., mental health, acupuncture, physical therapy)

• Telemedicine access

• Wellness programs

• Out-of-network rules

It’s smart to review the Summary of Benefits and Coverage (SBC) document provided by your health insurance company to see what changed.

7. You Want Alternative or Holistic Care Options

Many traditional plans offer little or no coverage for holistic pain or wellness treatments — such as acupuncture, chiropractic, physical therapy, biofeedback, nutritional consults or naturopathic care.

Switching to a plan that offers integrative or expanded networks can support a more holistic approach to health, reduce pain, and lower medication dependence.

8. You Simply Haven’t Compared Plans in Years

Millions of Americans stay in the same plan out of habit, even when better options exist. A quick annual review — especially during open enrollment — ensures you’re not overpaying or missing out on new benefits.

If you get your insurance through an employer:

Employers with more than 50 employees are required to offer them health insurance, but are not required to offer multiple insurance options, however some do.

Common Employer Practices

Even though it’s not required, many employers offer more than one plan to attract and retain workers. Examples include:

• A choice between an HMO and a PPO

• A traditional plan and a high-deductible plan with an HSA

• Different coverage tiers (e.g., Bronze, Silver, Gold-level plans)

• Buy-up options that include extra benefits like dental, vision, or wellness perks

 Offering choices can improve employee satisfaction but also increases administrative complexity and cost for employers.

Summary of Why You Should Re-Evaluate Your Health Insurance Options

You should consider changing your health plan if your life, health, or budget has changed — or if your plan has.

 Open enrollment is your once-a-year opportunity to make sure your coverage truly fits your needs, supports your preferred healthcare providers, and makes financial sense.

Factors to Consider When Choosing the Type of Plan

Health insurance in the United States is much more expensive (more than twice as much) than anywhere else in the world, as is healthcare itself. This is largely because our healthcare system is largely driven by profits and is very fragmented. The latter is also why making decisions about insurance can be so complicated. 

In general, insurance plans which have more limits on your choice of providers and more of a say in which treatments you can receive (such as predeterminations or medical necessity reviews or referral requirements to see a specialist) have lower premiums, deductibles and copays. 

If you have limited discretionary income to spend on health insurance, you may not have much of a choice about which type of plan you can enroll in but you may have choices among different insurance plans of the same type, such as HMOs. 

If you can afford it, it is usually wiser to choose a plan where you have more choices and fewer limits, especially if you suffer from a chronic condition. You will have more options to go to the best specialists for your condition, even if they are out of the area, and have more choices of treatments and drugs. Some plans will offer you more alternative treatments with fewer visit limits for chiropractic, physical therapy, acupuncture and occupational therapy than others. You will likely, in the end, have lower overall out-of-pocket costs as a result despite the higher premiums.

Major Types of Health Insurance Plans in the U.S.

1. HMO (Health Maintenance Organization)

How it works:You choose a primary care physician (PCP) who coordinates all your care. You must get referrals to see specialists, and coverage is limited to doctors and hospitals within the HMO network (except emergencies).

✅ Pros:

• Lower premiums and out-of-pocket costs

• Predictable copays

• Coordinated care through your PCP

• Focus on preventive care

❌ Cons:

• No coverage for out-of-network providers (except emergencies)

• Must get referrals for specialists

• Limited provider choice

Best for: People who can’t afford a more expensive plan or who want lower costs and don’t mind staying within a network or using referrals. This is less of a problem for those without chronic health conditions. Keep in mind, however, that health status can change in the course of a year.

2. PPO (Preferred Provider Organization)

How it works:You can see any provider, but you’ll pay less if you use those in the plan’s preferred network. No referral needed to see specialists.

✅ Pros:

• Freedom to choose any doctor or specialist

• No referral required

• Partial coverage for out-of-network care

❌ Cons:

• Higher premiums and deductibles

• More paperwork if you go out-of-network

Best for: People who want flexibility in choosing providers and are willing and able to pay more for it.

3. EPO (Exclusive Provider Organization)

How it works: A hybrid between HMO and PPO. You don’t need referrals, but no out-of-network coverage is provided (except emergencies).

✅ Pros:

• Lower cost than PPOs

• No referrals required

• Access to specialists within the network

❌ Cons:

• No out-of-network coverage

• Limited provider network

Best for: People who want some flexibility but can stay within a defined network.

4. POS (Point of Service Plan)

How it works: Combines features of HMO and PPO. You choose a primary doctor but can go out-of-network at higher cost. Referrals are needed for specialists.

✅ Pros:

• Some out-of-network coverage

• Coordinated care through a PCP

• Often lower costs than PPOs

❌ Cons:

• Requires referrals

• Higher cost when using out-of-network care

Best for: People who want some flexibility but don’t mind working through a PCP.

5. HDHP (High Deductible Health Plan) with HSA Option

How it works: Plans with higher deductibles but lower premiums. Often paired with a Health Savings Account (HSA) that lets you save pre-tax money for medical expenses. Sometimes and employer will contribute to an HSA account.

✅ Pros:

• Lower monthly premiums

• Tax-free HSA savings for medical expenses

• Good for healthy individuals with low medical costs

❌ Cons:

• High out-of-pocket costs before insurance kicks in

• Can be financially risky if major illness occurs early in the year

Best for: Healthy individuals who want to save on premiums and can afford higher deductibles if needed.

6. Catastrophic Health Plan

How it works: Available to people under 30 or those with hardship exemptions. It covers essential benefits but only after a very high deductible is met.

✅ Pros:

• Very low premiums

• Protects against major unexpected medical costs

❌ Cons:

• Doesn’t cover most routine care until deductible is met

• Not eligible for ACA subsidies

Best for: Young, healthy individuals who want minimal coverage mainly for emergencies.

7. Medicare

How it works: You must enroll in Medicare if you are 65+ or disabled. There are two options: traditional (original) Medicare and Medicare Advantage. 

Traditional Medicare Includes:

• Part A: Hospital care

• Part B: Outpatient/doctor services

• Part D: Prescription coverage (Must be selected and purchased separately)

✅ Pros:

• Broad access to providers nationwide

• Standardized benefits

• Optional add-on: Medigap, which covers some deductibles and copays

❌ Cons:

• Can have gaps (e.g., dental, vision, hearing not covered)

• Multiple premiums/deductibles 

Best for: Seniors who want the optimum flexibility in selecting providers and treatments, people with chronic conditions who can afford the higher premiums.

Medicare Advantage:

Functions similarly to an HMO

✅ Pros:

• Lower premiums

• Simpler sign-up: Parts A, B, D are included 

• Often includes dental, vision, hearing, gym 

❌ Cons:

• Only in-network providers and services are covered

• Referrals are required for specialists and specialist care can be denied

• There may be more limits than in original Medicare on visits to physical and occupational therapists and chiropractors

• You cannot purchase a Medigap plan, though there are out-of-pocket limits on expenses

Best for: Seniors who are in relatively good health or who can’t afford to pay the higher original Medicare, Part D and Medigap premiums or to pay for dental and vision care.

Medicare Automatic Enrollment After 24 Months of Disability Benefits

If you receive Social Security Disability Insurance (SSDI) — not SSI — you are automatically enrolled in Medicare after a waiting period:

• You become eligible for Medicare after receiving SSDI for 24 months.

• On the 25th month of receiving SSDI, your Medicare coverage begins automatically.

• You’ll receive your Medicare card in the mail a few months before your coverage starts.

This automatic enrollment includes:

• Part A (Hospital Insurance) — usually premium-free

• Part B (Medical Insurance) — optional, but automatically included unless you decline it

You Can Decline Part B (but think carefully before doing so)

• If you have other creditable coverage (for example, through a spouse’s employer), you can choose to delay Part B to avoid paying its monthly premium.

• However, if you decline Part B without other qualifying coverage, you may face a permanent late enrollment penalty if you sign up later.

“Creditable coverage” means insurance that’s at least as good as Medicare — most large employer plans qualify, but short-term, COBRA, or Marketplace plans usually don’t.

Part D (Prescription Drug Coverage) Is Not Automatic

You are not automatically enrolled in Part D.

• You’ll need to choose a standalone Part D plan or a Medicare Advantage plan (Part C) that includes drug coverage.

• If you wait to enroll and don’t have other creditable drug coverage, you’ll face a Part D late enrollment penalty later.

If You’re on SSI (Supplemental Security Income)

If you receive SSI, you generally qualify for Medicaid, not Medicare (unless you’re also eligible for SSDI).

• Many people with disabilities receive both Medicare and Medicaid — known as “dual eligibility.”

  • Medicare acts as the primary payer

  • Medicaid helps cover premiums, deductibles, and copays

8. Medicaid

How it works: Joint federal-state program for low-income individuals and families. Eligibility varies by state in terms of what income quailifies.

✅ Pros:

• Usually free or very low-cost

• Covers a broad range of services, including preventive and long-term care

• No open enrollment limits — apply anytime

❌ Cons:

• Limited provider choice in some areas

• Income and asset limits may affect eligibility

Best for: Low-income individuals, children, pregnant women, and people with disabilities.

9. Short-Term or Limited-Duration Health Plans

How it works: Temporary insurance (usually 1–12 months) for people between jobs or waiting for other coverage.

✅ Pros:

• Low premiums

• Quick approval

• Flexible short-term option

❌ Cons:

• Often excludes preexisting conditions

• May not cover essential health benefits (maternity, mental health, prescriptions)

• Not ACA-compliant

Best for: People who need temporary coverage and understand its limitations.

Conclusion

Choosing the best type of coverage can be a daunting task given the complexity of the American healthcare system, however it’s a worthwhile effort to ensure you’re getting the best healthcare you are able to afford.

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This article originally appeared on the Alternative Pain Treatment Directory: https://www.paintreatmentdirectory.com/posts/open-enrollment-choose-the-best-health-plan-for-your-needs