The fall coverage checkup: what to review before open enrollment closes

What to look at every fall, in one paragraph

Every fall, read your plan's notice of changes for next year, confirm your doctors and hospitals are still in network, check every prescription against next year's drug list, compare what you actually spent this year with what the plan will cost next year, and note your enrollment deadline. For Medicare, the window is October 15 to December 7. For Marketplace plans, Open Enrollment runs November 1 to January 15, with December 15 the deadline for coverage starting January 1. Employer plans set their own dates. If nothing important changed, renewing is fine; if something did, compare alternatives before the deadline.

I am Rex Slover, and at Slover Agency I help people on Medicare, families with individual plans and employers around Murphy, Plano and Dallas go through this review each year. Most of the calls I get in January about surprise bills trace back to a change that was announced in the fall and never read. Here is the checklist I use.

• Read the notice of changes from your plan or employer
• Recheck doctors, specialists and hospitals in next year's network
• Check each prescription on next year's drug list
• Compare this year's real costs with next year's premium and cost-sharing
• Mark the enrollment deadline that applies to you

Start with the letter most people throw away

If you are in a Medicare Advantage or Part D plan, Medicare.gov explains that your plan sends a Plan Annual Notice of Change each fall, typically in September, listing changes in coverage, costs and more that take effect in January. Medicare advises reviewing it to decide whether the plan will still meet your needs next year, and contacting your plan if you did not receive one.

Employer plans and Marketplace plans send their own versions: renewal letters, open enrollment packets and updated plan summaries. The format varies, but the questions are the same. What is the premium next year? Did the deductible, copays or out-of-pocket maximum change? Did the network or the drug list change? Write the answers on one page so you can compare them with any alternative you look at.

Keep last year's version of the same document if you still have it. Putting the two side by side is the fastest way to see what actually changed, and it often reveals a pattern, such as a deductible that has crept up several years in a row, that a single letter hides.

Recheck your doctors as if you were new

Networks change. A doctor or hospital system that was in your plan this year may not be next year, and the change often appears only in the fine print of a notice or in an updated directory. If your plan is an HMO, EPO or Medicare Advantage plan with a network, this check matters most, because out-of-network care may not be covered at all except in emergencies.

Search next year's directory for each doctor you see, including specialists and the hospital you would want for surgery. Then call the offices and ask whether they will accept your plan next year. It takes twenty minutes and prevents the most frustrating kind of surprise: learning in February that the doctor you have seen for years is no longer covered.

While you are on the phone, ask whether the practice expects any changes of its own, such as a doctor retiring or the group joining a different hospital system. Front desks often know about these moves months before they show up in any directory.

Run every prescription through next year's drug list

Drug lists, also called formularies, are updated for the new year, and a medication can move to a more expensive tier, pick up a prior authorization requirement, or drop off the list. This applies to Part D plans, Medicare Advantage plans with drug coverage, Marketplace plans and employer plans alike.

Make a list of every regular medication with its dose and check it against next year's formulary for your plan and for any plan you are considering. If a drug changed, ask your doctor whether a covered alternative would work for you, and factor the difference into your comparison. One expensive prescription can decide the whole question.

Compare this year's real costs with next year's plan

Pull your explanation of benefits statements or your plan's online summary and add up what you actually paid this year: premiums, deductibles, copays and coinsurance. Then look at what the same care would cost next year under your current plan and under one or two alternatives. A plan that suited you when you were healthy may be expensive now that you see a specialist monthly, and the reverse is just as common.

Think ahead as well. A planned surgery, a new baby, a move, retirement or a child aging off your plan all change what the right coverage looks like. If you know something is coming, the fall review is the time to plan for it.

If you have a health savings account or a flexible spending account through work, look at the balance and your planned contributions for next year at the same time. The account and the plan work together, and a higher deductible next year may call for setting more aside. Your tax preparer can help with the rules that apply to your account.

If you are on Medicare: October 15 to December 7

Medicare.gov describes Open Enrollment as running from October 15 to December 7, with the plan required to receive your enrollment request by December 7 and changes taking effect January 1. During that window you can join, drop or switch Medicare Advantage plans, join, drop or switch a standalone Part D plan if you have Original Medicare, and move between Original Medicare and Medicare Advantage.

One caution: moving from Medicare Advantage back to Original Medicare does not guarantee you can add a Medicare Supplement, because outside your initial Medigap window insurers may consider your health. I explain that rule in Medicare Advantage or a Medicare Supplement. If you or your spouse are still working past 65, review how your employer coverage and Medicare fit together as well; whether you need Medicare at 65 if you are still working covers that.

If you buy your own plan: November 1 to January 15

HealthCare.gov lists Open Enrollment for Marketplace plans as November 1 through January 15, with December 15 as the last day to enroll or change plans for coverage starting January 1. If you do nothing, many people are renewed into the same or a similar plan, but that plan may have a new premium, network or drug list.

Update your income estimate for next year as part of the review, since savings on Marketplace plans depend on it. If your income has risen or fallen, or your household has changed, the right plan and the savings you qualify for may be different. Before you switch to something cheaper, read the health plan mistakes I see every enrollment season.

If you run a business: renewal and employee enrollment

Employer plans renew on their own schedule, often but not always on January 1. The review for an employer has two parts. First, decide whether to keep, restructure or replace the plan, ideally starting about two months before the renewal date so there is time to shop. Second, run an employee open enrollment where people can choose plans, add or drop dependents and update their elections.

If the renewal came in higher than you expected, my guide on what to do when a group health renewal goes up walks through the options. Remind employees approaching 65 to check how Medicare fits with your plan, and make sure anyone with a health savings account knows what changes next year.

Keep the employee side simple. A short meeting or a one-page summary that explains what changed, what it costs per paycheck and the deadline to make changes prevents most of the questions that would otherwise land on your desk in January.

Do not forget the coverage around the medical plan

The fall is also the time to look at the policies that sit beside your health plan. My agency's individual benefits page describes dental plans that cover preventive care such as routine exams, cleanings and X-rays, and pay 50 to 80 percent of basic and major care, and vision plans that cover routine eye care up to a preset limit. If you skipped them last year and needed dental work, it may be worth reconsidering.

Life insurance and disability income protection deserve a look when your family or income changes. And if you have a big trip planned next year, especially abroad, check what your health plan covers away from home; travel medical and evacuation coverage exist for exactly that gap, and I can quote them.

• Dental: what you used this year and what major work may be coming
• Vision: exams, glasses and contacts for the household
• Life: whether coverage still fits your family and debts
• Disability: whether your income would be protected if you could not work
• Travel medical: coverage for trips outside your plan's area

Book the review once and let me do the legwork

If you would rather not do this alone, send me your plan's notice of changes, your doctors and prescriptions, and anything you expect next year. I will check networks and drug lists, compare your current plan with alternatives across carriers, and tell you plainly whether to stay or switch. Many years the answer is to stay, and that is a perfectly good outcome.

The review costs you nothing, because carriers pay the broker. For people on Medicare, employers with renewals and families buying their own coverage in the Dallas area and across Texas, the best time to start is as soon as the notice arrives, well before the deadline.

Questions people ask me