Why an Annual Review Matters

Health insurance plans are not static. Insurers adjust premiums, networks, drug formularies, and cost-sharing every year — and those changes take effect whether or not you review them. If you do nothing during open enrollment, you may be auto-renewed into a plan that no longer fits your situation.

This checklist walks you through every layer of your health coverage so you can make a deliberate, informed decision rather than a default one. It pairs well with our broader personal insurance review checklist if you want to audit other coverage types at the same time.

This article provides general health insurance information for educational purposes only. It is not personalized insurance, financial, or legal advice. Coverage terms, costs, and eligibility vary by insurer and state. Always read your actual plan documents and consult a licensed insurance agent or broker for guidance specific to your situation.

Open Enrollment Has a Hard Deadline

For marketplace plans, open enrollment typically runs from November 1 through mid-January, with enrollment by December 15 generally required for January 1 coverage. Employer plans set their own windows, often in the fall. Miss your window and you generally cannot change plans until the next year unless you experience a qualifying life event such as marriage, the birth of a child, or job loss.

What You'll Need Before You Start

Gather the following documents so you can work through the checklist efficiently without stopping to search:

Required

Current plan Summary of Benefits and Coverage (SBC)

The SBC is a standardized 4-page document that outlines your plan's costs, coverage, and key exclusions — your starting point for any review.

Required

Your insurer's online provider directory

Use this to verify that your doctors and hospitals are in-network for the upcoming plan year.

Required

Plan formulary (drug list)

This document lists all covered medications and their cost tiers so you can confirm your prescriptions are covered.

Optional

Explanation of Benefits (EOB) statements from the past year

EOBs show what you actually paid for care, helping you estimate realistic annual spending under your current plan.

Optional

Healthcare.gov or your employer's benefits portal

Use this to compare available plans side-by-side during open enrollment before making a final decision.

The Review Checklist

Work through each group below. Items marked must are non-negotiable before you make any renewal decision. Should items are strongly recommended. Nice-to-have items add useful context if time allows.

Know Your Current Plan's Cost Structure

Locate your monthly premium and confirm whether it is changing in the upcoming plan year. Must
Note your annual deductible — the amount you pay out-of-pocket before your insurer starts sharing costs. Must
Find your out-of-pocket maximum — once you hit this figure, the plan pays 100% of covered costs for the rest of the year. Must
Review your copays and coinsurance rates for primary care, specialist, urgent care, and emergency visits. Should

Verify Your Network Coverage

Confirm that your primary care physician and any specialists you see regularly are still in-network for the upcoming plan year. Must
Check that your preferred hospital or health system remains in-network, especially for any planned procedures. Must
If your plan is an HMO or EPO, confirm there are no out-of-network benefits — these plan types generally pay nothing for out-of-network care except emergencies. Must
Look up telehealth coverage terms, including whether virtual visits count the same as in-person visits toward your deductible. Should

Review Prescription Drug Coverage

Pull your plan's drug formulary (the official list of covered medications) and verify all your current prescriptions are included. Must
Check which tier each of your medications falls into, since tier level determines your copay or coinsurance amount. Must
Confirm whether any medications require prior authorization or step therapy before the plan will cover them. Should

Account for Life Changes

Identify any qualifying life events from the past year — marriage, divorce, a new child, or loss of other coverage — that may affect your plan eligibility or dependents. Must
Update your covered dependents list to reflect births, adoptions, or adult children who have aged off your plan. Must
If your income changed significantly, check whether you now qualify for different premium tax credit amounts or Medicaid eligibility. Should
Consider any anticipated care needs for the coming year — planned surgery, pregnancy, or ongoing specialist care — and model out estimated costs under each plan option. Should

Check Benefits You May Be Underusing

Review which preventive services your plan covers at $0 cost-sharing, as required under the Affordable Care Act for most non-grandfathered plans. Should
Check whether your plan includes a Health Savings Account (HSA) or Flexible Spending Account (FSA) option, and confirm you are contributing if eligible. Should
Look into any wellness programs, gym reimbursements, or mental health benefits included in your plan that you haven't taken advantage of. Nice to have

Once you know which preventive services your plan covers at no cost, cross-reference with our annual preventive care checklist for adults to make sure you're scheduling everything you're entitled to.

Network Changes Happen Every January

Even if your doctor was in-network last year, that can change. Providers and insurers renegotiate contracts annually, and a provider can drop out of a network without individual notice to policyholders. Always reconfirm network status directly with both your provider's office and your insurer before assuming coverage will continue.

Putting It All Together

After completing the checklist, you should have a clear picture of three things: what your current plan actually costs you (not just the premium), whether it still covers the providers and medications you rely on, and whether a different plan tier might be a better financial fit given the care you expect to need.

If your health spending is difficult to predict, pay close attention to the out-of-pocket maximum — the most you'll pay in a plan year before insurance covers 100%. A plan with a higher premium but lower out-of-pocket maximum can cost less overall if you use significant care.

For help fitting premiums and cost-sharing into your broader household spending plan, see the Budgeting Basics hub. And if this review reveals changes in your overall insurance picture — a new dependent, a home purchase, or a change in income — use the annual insurance coverage checklist to assess all your policies together.