Open Enrollment: 8 Smart Questions to Ask Before Choosing a Health Plan

By Brian Kuchnicki, St. Louis Market President

Here’s the good news: with a little preparation and the right questions, you can find a plan that fits your life, your budget, and your health needs. These eight questions can help guide your decision-making this open enrollment season.

What kind of health plan fits my needs—and what are my options?

Start with your health story. Do you take regular prescriptions? See specialists? Have any chronic conditions or ongoing medical needs? Need mental health support? Or do you just want peace of mind?

Then ask yourself these key questions to narrow down your options:

Do I have access to affordable employer-sponsored coverage (through my job or a spouse)?

• Yes: This is often your most affordable and straightforward option.
• No or it’s too expensive: You may qualify for subsidies in the Marketplace.

Am I eligible for Medicaid?

• Yes: Medicaid offers free or low-cost coverage based on income.
• No: Continue exploring Marketplace or other options.

Am I eligible for Medicare?

• Yes: If you’re 65+ or have a qualifying disability, Medicare is your primary option.
• No: Investigate Marketplace or employer coverage.

Do I qualify for subsidies in the individual market?

• Yes: Shop through the Marketplace to access financial help and streamlined enrollment.
• No: You can still buy coverage directly from insurers or through a broker, but without subsidies.

This decision tree helps you quickly assess your situation and find the right path to coverage—whether it’s through work, a government program, or the individual market. 

How can I find affordable coverage—and am I eligible for financial help?

• Most people qualify for help. If your income is between 100% and 400% of the federal poverty level, you may get subsidies through the Marketplace. In fact, 4 out of 5 enrollees can find plans for $10/month or less.

Families may also qualify for:

• Medicaid or CHIP (for kids and adults)
• Employer plans with lower premiums

Healthcare.gov will estimate eligibility for Medicaid, but not employer plans.

How do I know if my doctor is in-network?

This one trips up a lot of people. Staying in-network can save you hundreds—or even thousands.

Tips:

• Call your doctor’s office before any of your appointments
• Use your insurer’s provider search tool or call your insurance member service team.

What if I need coverage outside the Marketplace—or I’m turning 26?

You can buy insurance directly but be cautious. These plans:

• Don’t offer subsidies
• May lack essential benefits
• Could be short-term or limited

If you're turning 26 and aging off a parent’s plan, you qualify for a Special Enrollment Period—60 days before or after your birthday. Explore all plan options. Prepare before turning 26.

Why do subsidies matter when choosing a health plan?

• Subsidies—also known as premium tax credits—can significantly lower your monthly health insurance costs. Most people shopping on the Marketplace qualify based on income, and some can find plans for as little as $10/month. Subsidies make coverage more affordable and accessible, especially for families, young adults, and those without employer-sponsored insurance. If you're not checking your eligibility, you could be missing out on major savings.

Do HSAs or FSAs offer real benefits?

Yes. These accounts let you set aside pre-tax dollars for medical expenses:

• Health Savings Account (HSA) is a tax-advantaged savings and investment account for medical expenses with high-deductible plans. They offer long-term savings, investment options, and rollover benefits. HSAs are especially useful for retirement planning or future health costs.
• Flexible Spending Account (FSA) is offered by employers. It’s a “use-it-or-lose-it” pre-tax dollars but gives upfront access to funds for eligible health care expenses 

What should I watch for with Medicaid and yearly plan changes?

Medicaid eligibility varies by state and income. Some states are expanding coverage, while others are adding new requirements.

Even if you love your current plan, review it annually. Your plan may:

• Change provider networks
• Adjust drug coverage
• Raise premiums or deductibles

How do I compare prescription drug coverage?

If you take regular medications—or even just a few throughout the year—this is a big one. Not all health plans treat prescriptions the same, and the differences can be costly. Here’s what to look for:

• Formulary: This is the plan’s list of covered drugs. Make sure your medications are on it.
• Tiers: Drugs are often grouped into tiers (generic, preferred brand, non-preferred, specialty). Each tier has different copays.
• Pharmacy network: Some plans only cover prescriptions filled at specific pharmacies. Make sure your preferred pharmacy is in-network.

Final Thought

Open enrollment doesn’t have to be overwhelming. With the right questions—and a little help—you can find coverage that works for you and your family. Whether you're navigating the Marketplace, exploring Medicaid, or comparing employer plans, take time to review your options. Your health—and your wallet—will thank you.