The official 2025 Open Enrollment Guide + FAQs

Why is Open Enrollment limited to specific dates?

Health insurers limit the open enrollment period to prevent adverse selection.  Adverse selection happens when sick people sign up for a health plan, but healthy people don’t, which throws the amount of risk a health plan takes on out of balance when insuring someone.

Where can you buy individual insurance?

During open enrollment, insurance plans are available from major medical insurance companies to purchase from “the marketplace” or “exchange.” These plans are referred to as  “on-exchange” plans. Most states use the federal exchange, Healthcare.gov. Some states, like California, New York, Pennsylvania, and a few other states, have their own state-run exchanges and enrollment systems. 

When you shop at Healthcare.gov, you’re only seeing “on-exchange” plans. However, insurance companies only make a fraction of their plans available “on exchange.” If you go directly to an insurance company’s website, you’ll see their “off-exchange” plans.

The Take Command platform is a great place to start shopping because you can look at ALL of the available plans side by side (including “off-exchange” plans) to compare – and see which plans are “Easy-Enroll”. True to the name, Easy Enroll plans have easy, fast enrollment (Take Command takes care of it!) and our team can support you with the Carrier! Look for the Easy Enroll tag for added peace-of-mind.

If you’re ready to start shopping, you can view all of your options side by side on our platform.

What is “the marketplace” or “exchange”? 

The Affordable Care Act created a health insurance exchange, or online marketplace, where individuals can shop for individual health insurance plans and compare their health plan options. This is known to most as Healthcare.gov. Individuals are only eligible to receive premium subsidies and cost-sharing reductions if they purchase their coverage through the exchange.

Why is Open Enrollment significant for me?

Because your employer is offering you a health reimbursement arrangement, now is the time to purchase your plan for coverage starting on January 1st, 2025. It’s important to note that you’ll need to enroll by December 15th, 2024 for coverage that starts January 1st, 2025. Open enrollment continues through January 15th for February 1st start dates. As mentioned above, the dates may vary slightly in some states.

Open Enrollment is the time when you can buy a compliant plan that is qualified for your HRA (either a qualified health plan for ICHRA or a Minimum Essential Coverage plan for QSEHRA). If you’re a client already using our platform, there will be a to-do list on your dashboard. If you are new here, we will walk you through onboarding which will include shopping for a plan. After Open Enrollment begins in November, you’ll receive an email to log in and get started shopping for individual health insurance.

Section 2: How To Buy Individual Insurance

How do you buy individual insurance?

It can be a little overwhelming! Before you shop, start by thinking about what’s important for you and what health needs you anticipate for the year. Good questions to ask yourself include, Is it more important to have a low premium or a low deductible? Do you regularly see a specialist that needs to stay in-network? Do you have a lot of prescriptions that you’ll need covered? Are you anticipating any medical needs this year (i.e., ongoing physical therapy, surgery, or pregnancy?)

It’s good to think these things through, because what really drives costs–and therefore your plan choice–are the things you know about: prescriptions, doctor visits, therapy, medical equipment, etc. If you’re healthy, maybe you plan on none of these things–which is just as important to know. Unpredictable costs, like catching a cold, spraining an ankle, or a hospitalization, shouldn’t impact your plan choice. 

Our shopping portal allows you to enter a provider’s name to see which plans show them as in-network and see if specific prescriptions are covered in a plan’s drug formulary.

More than 75% of your healthcare costs in the next year are predictable based on your needs.

How do you know you’re getting the best price for your plan?

Here’s some good news for simplicity: any given plan sold during Open Enrollment will be priced exactly the same no matter where you find it. If you find a plan you like, say a Blue Cross Blue Shield silver plan on Healthcare.gov, it will legally be priced the same whether you purchase it on the Exchange, or from a broker friend. 

The prices on our individual health insurance shopping portal will show you the best prices for all of your health plan options. 

How do you know if the plan you want to buy qualifies for your company’s HRA?

Gather round, friends. This is a really important question. Why? Because not all plans integrate with HRAs, meaning that not all plans will be reimbursed through an HRA and not all plans will qualify you to participate in your company’s HRA. Best to get this right the first time. 

Here’s an easy, quick list to get started:

ICHRA-compliant plans:

Plans that don’t work with ICHRA include sharing ministries, TRICARE, short term and indemnity plans, and other employer sponsored group plans (either from spouse, COBRA, or retirement plan). 

QSEHRA-compliant plans:

Section 3: What are Premium Tax Credits?

What are Premium Tax Credits?

Premium tax credits, also known as PTCs, are refundable credits (or subsidies) that helps eligible individuals and families cover the costs of premiums for their health insurance purchased through the ACA Marketplace, or Exchange. To receive a premium tax credit, you must meet certain requirements.

One way to pay too much for health insurance is to leave money on the table. We see many individuals assume they’re not eligible for tax credits when they actually are. Depending on where you live, a family of 3 or 4 that makes $90,000 a year will likely qualify for a tax credit.   

Our individual health insurance shopping portal will help you calculate your premium tax credits if you qualify. 

How do you know if you qualify for Premium Tax Credits?

Generally speaking, tax credits are tied to size and income. They also vary across zip codes. You may qualify for premium tax credits if you: 

• Fall within a certain income range
• Cannot be claimed as a dependent 
• Do not file a tax return using the filing status of Married Filing Separately
• Have health insurance coverage through the marketplace or exchange.
• Are not able to get affordable coverage through an eligible employer-sponsored group plan that provides MEC.
• Are not eligible for coverage through a government program, like Medicaid, Medicare, CHIP or TRICARE.
• Pay the share of premiums not covered by advance credit payments.

Take Command Health can help you figure out how much you are eligible for on our individual health insurance shopping portal. 

How will your HRA affect your Premium Tax Credits?

This is a tricky one. The way HRAs and PTCs interact depends on what type of HRA you have. 

In general, QSEHRA allowance will reduce premium tax credits dollar for dollar.

Basically the employee will be exchanging the tax benefit from the government with the tax benefit from the employer. The employee may still access their tax credits if the benefit is less than the premium tax credit available to them. 

As an example, if you are eligible for a $500 tax credit and your employer offers a $400 QSEHRA allowance, your PTC will be reduced to $100 ($500-$400). 

It is very important that employees purchasing a plan through the marketplace and receiving a premium tax credit notify their insurance provider immediately about their small business HRA benefit.  The insurance provider will recalculate the employee tax credit with the QSEHRA benefit. Failure to report the QSEHRA to your insurer will result in having to pay back the tax credits to the IRS during tax time.

FOR ICHRA: If you have an ICHRA, here’s what you should know about PTCs and ICHRA.

Employees can choose to participate in ICHRA or receive a PTC. You cannot have both.

A nice feature of the individual coverage HRA is that as an employee, you have the option to participate in your employer’s ICHRA or opt-out annually through the opt-out provision. This is different then ICHRA’s predecessor, QSEHRA, which does not allow employees to opt-out. 

If you accept the Individual Coverage HRA, you cannot claim any premium tax credits for the year for either yourself or any family members. If you opt-out of the Individual Coverage HRA for the year, you may be able to claim premium tax credits.

The Exchange will then determine if the ICHRA offered is deemed affordable or unaffordable for you. In cases where an employee has opted out of ICHRA and the HRA is considered unaffordable the employee is allowed to claim premium tax credits for themselves and dependents. In cases where the employee has opted out of ICHRA and the coverage is deemed affordable the employee may not claim any premium tax credits for themselves or dependents. 

When individuals enroll in an Exchange plan, the Exchange will ask if the individual is offered any coverage through their employer. This includes coverage through the Individual Coverage HRA. Employees will be required to give notice to the Exchange of their ICHRA offering. 

During the onboarding process with Take Command, we will help you understand these nuances and determine what’s best for you.

How can you get more information about Premium Tax Credits?

First stop, look at your plan documents on your portal. The employee notice, specifically, will have great information on what to do about your PTCs that’s tailored to you and your exact plan. Also check out the following resources:

Section 4: Other Open Enrollment FAQs

What is an “on-exchange” or “marketplace” plan?

An on-exchange, or marketplace plan, is a health insurance plan that’s purchased on the ACA marketplace or federal exchange (a.k.a. Healthcare.gov.) or, in some states, state-run exchanges. Any of these are considered marketplace plans and are eligible for premium tax credits.

What is an “off-exchange” plan?

Off-exchange plans are offered by major medical providers and purchased directly through them instead of from the exchange. 

Our individual health insurance shopping portal shows both on- and off-exchange options. 

Can I buy a plan that’s not sold on the exchange? Are there other options besides Obamacare (ACA)?

In general, there are other plans outside of the ACA plans and the off-exchange plans mentioned above. But remember, you need to have a plan that qualifies for reimbursement through your employer’s HRA. For QSEHRA, there are some alternative insurance plans that qualify if certain conditions are met. We can guide you through the process of weighing your options and connect you with a partner we trust. 

If you’re enrolled in an ICHRA, however, you’ll need an individual medical plan. We recommend you utilize open enrollment to shop for an on- or off-exchange major medical plan that integrates with ICHRA. 

What do the metal tiers mean? (Bronze, Silver, Gold, Platinum)

What the metal tiers are telling you is how much the plan covers and how much it costs.

Here’s the gist:

Bronze:

• You rarely get sick or need medical services, apart from an annual checkup and maybe a medication or two.
• You are very healthy and not elderly.
• If buying a family plan, your children are grown and healthy and don’t participate in risky activities.  
• Expect to pay 40% out of pocket, 60% paid by your plan

Silver:

• Your family members have one or two mild conditions that require some medication and specialist visits, but nothing needing close monitoring or frequent care.
• Your family members are able-bodied and under 70.
• Any kids are elementary age or older and healthy, and play few or no sports that often cause injury.
• Expect to pay 30% out of pocket, 70% paid by your plan

Gold:

• You or a family member has a chronic condition, sees doctors frequently or needs expensive medication that would be impossible to afford out of pocket.
• Your children are preschool age or younger, needing frequent pediatrician visits.
• You may be older or at a higher risk for colds and flu than most people.
• Expect to pay 20% out of pocket, 80% paid by your plan

Platinum:

• You or a family member has an expensive chronic condition and takes several medications.
• You seek urgent or emergency care more than once per year on average, frequently need exams to manage a condition or see doctors more than once per month.
• You are older or at very high risk for colds, flu, or injuries.
• Expect to pay 10% out of pocket, 90% paid by your plan

What are insurance “premiums” and “deductibles”?

A premium is the monthly cost for your health insurance. The premium is what your monthly allowance for an HRA will cover.

A deductible is the amount of covered healthcare costs you pay before your health insurance begins to cover the costs. If you have a $2,000 deductible, you’ll be paying $2,000 out of pocket before insurance kicks in. 

Pro-tip: Your monthly premium does not count toward your deductible. 

What are the differences between the network types (HMO, PPO, EPO)?

An HMO (or “health maintenance organization”) is generally the most affordable, but least flexible network type. Here a few key concepts of a HMO:

• You are required to select a primary care physician (or the insurance company can assign one for you) who is your first-stop for health needs. You will need a referral from your primary care physician to see a specialist.
• If you choose to see a doctor outside of the network or without a referral, you will generally have to pay all costs out-of-pocket unless it is a true medical emergency or you have no other options.
• The physician network is local.

A PPO (or “preferred provider organization”) is generally the most flexible, yet most expensive network type. Here a few key concepts of a PPO:

• You do not need to select a primary care physician and you do not need referrals to see a specialist.
• If you see an in-network provider, you will only be responsible for paying a portion of the bill (based on your plan’s coverage structure).
• If you choose to see a doctor who is outside the preferred network, you will generally have to pay a larger portion of the bill than you would for an in-network provider.
• You will have access to out-of-state providers that are considered in-network.

An EPO (or “exclusive provider network”) is a hybrid of a HMO and a PPO. Here a few key concepts of an EPO:

• EPOs are more flexible than an HMO, and are typically less expensive than a PPO.
• Like a PPO, you do not need a referral to get care from a specialist.
• Like an HMO, you are responsible for paying out-of-pocket if you seek care from a doctor outside your plan’s network.

A POS (or “point of service”) is also a hybrid of a HMO and a PPO. Here are a few key concepts of a POS:

• POS plans are more flexible than an HMO, and are typically less expensive than a PPO.
• Like an HMO, you will need a referral from your primary care physician in order to see a specialist.
• Like a PPO plan, you will have access to out-of-network providers (at an increased cost).

Can I change health insurance plans in the middle of the year?

You can only change plans and buy on-exchange plans during Open Enrollment (from November 1st through January 15th) unless you meet certain conditions that qualify you for a Special Enrollment Period. These circumstances include having a baby, getting married, getting divorced, or changing jobs. In other word, big life changes.

If you are offered an HRA for the first time from your employer, that qualifies you for a Special Enrollment Period as well, where you’ll have 60 days to sign up for a health plan that meets your HRA requirements. 

Pro-tip: We recommend you take advantage of Open Enrollment to sign up for a plan. You’ll have more options.

Read our posts on Special Enrollment Periods for QSEHRA or Special Enrollment Periods for ICHRA for more info. 

What about dental insurance? 

There are two ways to enroll in dental insurance.

1. The Marketplace: Dental plans sometimes are included in health plans sold on the Marketplace or state-based exchanges. When you compare plans on our window shopping tool or even on Healthcare.gov, you’ll be able to see which ones include dental coverage. In these cases, your premium would cover both health and dental coverage. 
2. Separate dental plans: If your health plan does not include dental coverage, you may to purchase a separate dental insurance plan. Just remember, if you pick a separate dental plan, you’ll pay a separate premium. This is in addition to the premium you pay for your individual health insurance plan. Sometimes, when you’re shopping on the Exchange, you’ll see an option to add a dental plan. This will provide further options for you. For our clients, we have researched quality individual health insurance plans through Renaissance and AmFirst that we recommend to use with an HRA. 

Here’s a helpful post for more information about our dental partnerships.

Next Steps

This is an exciting time, and we’re honored to a part of this process with you. If you have any other questions as you begin the process, please reach out. We are here to help you! And for those of you who are ready to being, please login to our portal and we’ll walk you through the process.

Happy Open Enrollment, everybody! 🎉