What you need to know before you renew your health insurance
Coverage and benefits
Network types and providers
Premiums and deductibles
Metal tiers
Star rating. How does your plan compare?
First, you need to know the start and end dates of open enrollment 2024. (plan year 2025). Second, you have to understand what has changed since open enrollment in 2023.
Open enrollment is your opportunity to reassure yourself that the same plan is still the best, most affordable health insurance plan to protect you and your loved ones through the 2025 plan year.
You may be confident that your plan for 2024, made this time last year, was the best available on the market. But, just as surely, it is probable that your family circumstances or the terms and conditions of your plan have changed.
Insurers design their plans to make it easy for you to let them roll over (passive renewal.) Open enrollment is your opportunity to review the changes in your family circumstances, financial or health, and the outlook for 2025. You may find another insurance provider or plan type (including supplementary/ ancillary plans such as dental/ vision insurance or hospital/out-of-pocket protection).
These plans do not have to come from the same provider, so it makes sense to talk to an independent advisor (agent/broker) authorized to operate in your state. An independent advisor can offer unbiased information on all the plan/provider options available in your location; by contrast, a tied agent can only provide the plans of the insurance provider to whom they are affiliated.
You are the best person to provide the information your advisor needs to suggest options for a health insurance portfolio that best meets your medical and financial criteria for 2025 and beyond.
That information and your personal preferences will enable your advisor to suggest two or three alternatives. Those alternatives will be based on your input and their knowledge of the plan options available in your state and the local providers/networks. (Surgeries, consultants, ER establishments, pharmacists, and care providers)
This is the point at which you need to be asking questions. These fall mainly into three categories.
- Coverage and Benefits
- Network type and providers
- Premiums and Deductibles
It is essential to be clear about what is covered by each plan and equally important to know what is not. What medical services (including preventive care) are covered by the plan, and what services are not? Are your prescribed medications in the provider’s formulary? To what extent do the suggested plans cover hospital stays and emergency operations? Are there supplementary or ancillary plans that address specific needs? Do doctors in the network offer telehealth services?
Each insurance provider partners with a network(s) of service providers (e.g., doctors, consultants, hospitals, surgeons, anesthetists, radiographers). Your access to these services is set out in your plan. Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans are the most popular.
As the name suggests, HMO plans assign the responsibility for coordinating your healthcare to a primary care physician (PCP). If you need to see a specialist, your PCP must refer you. HMO plans do not cover any out-of-network healthcare costs.
PPO plans are far less restrictive. You can choose any service provider within the insurer’s network (at a reduced cost) or an out-of-network service provider at ‘the list price.’ Although you do not need a referral to see a specialist, some states require you to have a primary care physician. Your insurance advisor will know your state regulations.
HMO plans typically have the lowest premiums, but a PPO plan may offer better value if you expect to need the services of out-of-network specialists.
Exclusive provider organizations (EPOs) and Point of service (POS) offer plans with monthly premiums that cost more than HMOs but less than PPOs and provide varying degrees of flexibility in accessing out-of-network providers.
Your premiums, the amount you pay each month to keep your health insurance plan in force, are determined by several factors: –
- choice of insurance provider
- choice of plan type, i.e., HMO or PPO
- choice of metal tier* (how you and your insurer divide the total cost of your insured medical and care costs)
- your personal details – age, zip code, family status, and tobacco usage
* Four metal tiers describe roughly how insurance plans split the costs between the insurer and the consumer: –
| Metal Tier | Insurer % | Consumer % |
| Bronze | 60 | 40 |
| Silver | 70 | 30 |
| Gold | 80 | 20 |
| Platinum | 90 | 10 |
Your premium is also influenced by the amount of your deductible (set out in your plan.)’ Deductibles are the amounts you must pay ‘out-of-pocket’ either in co-insurance or co-payments until your insurance steps in to pay 100% of your covered healthcare costs.
Generally, the more significant the share of the costs you are prepared to accept, the lower your premium.
