Group Employer Open Enrollment: Rising Costs, Smarter Options for Employers & Employees | RKA

Employer & Group Plans • Open Enrollment

Group Open Enrollment: Rising Costs, Smarter Options for Employers & Employees

Fast take: With medical inflation and rising utilization, many employer plans are increasing premiums and tweaking benefits this fall. Use open enrollment to compare — keeping the employee on the group plan, but placing a spouse/kids elsewhere can cut costs without giving up access. We’ll verify networks, prescriptions, and total annual cost before you choose.

Want a side-by-side group vs. alternatives analysis?

We’ll model employer plan costs next to marketplace and private PPO options for your household — including networks and Rx tiers.

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Why costs are climbing

• Medical inflation: Hospital, physician, and facility prices continue to outpace wage growth.
• Rx trend: Specialty drugs (including GLP-1 therapies) are widening plan spend.
• Higher utilization: Delayed care is catching up, pushing claims higher.
• Plan design shifts: Employers may raise deductibles/copays or adjust contributions to manage increases.

What to compare during open enrollment (October–December)

Employer plan checklist

• Employee vs. family premium contributions
• Deductible, copays/coinsurance, out-of-pocket max
• HSA/HRA funding and employer credits
• Network type (HMO/EPO vs PPO) and doctor/hospital fit
• Rx formulary & prior authorization rules

Compare against alternatives

• Marketplace: Check income-based subsidies; silver cost-sharing reductions if eligible
• Private PPO (underwritten): Often lower for healthy applicants; nationwide PPO access
• Spouse’s employer plan: Sometimes better dependent rates
• COBRA: Short-term bridge if switching mid-year

When keeping the group plan and splitting the family wins

Dependent premiums on employer plans can be steep. A common savings move: keep the employee on the group plan (to capture employer contribution and HSA access) and place a spouse or kids on marketplace or a private PPO if the numbers — and networks — work better.

Decision pathway

1. Send us your details: household members, providers, prescriptions, and employer plan options.
2. We verify networks & Rx: employer plan vs marketplace vs private PPO.
3. We model total annual cost: premium + likely usage + tax/HSA effects.
4. You pick and enroll: we execute cleanly and avoid gaps.

Tips for employers (quick wins)

• Offer an HSA-compatible plan with modest employer HSA seed to offset deductibles.
• Communicate a clear “how to compare plans” guide with provider verification steps.
• Consider ICHRA/QSEHRA strategies if group renewal is unsustainable.

Need a household or employer plan review before OE closes?

We’ll compare all viable paths and give you a simple, annual cost forecast — before you commit.

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Quick FAQs

Is the employer plan always best?

For the employee, often yes due to employer contribution. For dependents, not always — we frequently find savings by splitting coverage.

Can you verify our doctors and hospitals first?

Yes. We confirm providers by location and facility and cross-check Rx tiers before you enroll.

Can we switch mid-year?

Outside open enrollment, changes usually require a qualifying life event. Private PPO options may allow year-round starts if eligible.

Educational use only; benefits and eligibility vary by employer, carrier, and state. Always review official plan documents.

COBRA vs Marketplace vs Private PPO: What to Do Right After You Lose Employer Coverage

COBRA vs Marketplace vs Private PPO: What to Do Right After You Lose Employer Coverage

Laid off, new job, or between jobs? Here’s the fast, practical guide—costs, networks, deadlines, and how to decide in minutes. We’ll verify your doctors and show clear costs.

COBRA (keep your old plan)

• Same network/benefits you already know.
• Usually most expensive (you pay full premium + 2%).
• Time-limited (18 months); retroactive if elected on time.
• Good when in treatment and changing plans is risky.

Marketplace (Government)

• May be cheapest if your income qualifies for credits.
• Many plans are HMO/EPO; referrals are common.
• Mid-year move allowed due to loss of coverage.
• Credits reconcile at tax time—under-reporting income can create payback.

Private PPO (Licensed Access)

• Nationwide PPO when eligible; keep specialists/hospitals.
• Typically no referrals; fewer hoops.
• Advance premium tax credits do not apply to Private PPOs.
• Pricing = age, ZIP, benefits, and network.
• Great when you travel or want doctor choice.

What tends to cost more—and why

Why COBRA is often pricey

• You pay the entire employer premium + 2% admin fee.
• Large-group plan designs can carry higher OOP maxes.
• No income-based help.

How non-Marketplace Private PPO prices

• Based on age, ZIP, network size, and benefits.
• Good fits: provider choice, travel, specialist access, fewer referrals.
• We verify your doctors before you switch.

How to decide in minutes

Pick COBRA if…

• You’re mid-treatment and can’t risk network changes.
• You can stomach short-term higher premiums.
• You need exactly the same plan and doctors right now.

Pick Private PPO if…

• You want nationwide PPO and typically no referrals.
• You travel, use specialists, or dislike gatekeepers.
• Credits don’t help you—or you prefer not to use them.

We’ll compare all three with your doctors and meds, then show clear side-by-side costs.

Want the best post-employer fit in your ZIP?

We’ll verify your doctors and meds, compare COBRA vs Marketplace vs Private PPO, and show clear costs. No pressure—just answers.

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FAQ

How long do I have to elect COBRA?

Generally 60 days from the notice. If elected in time, coverage can be retroactive to the loss date (you’d owe premiums).

Can I switch from COBRA to other coverage later?

Yes. Marketplace: during Open Enrollment (or another qualifying event). Private PPO: typically year-round if you’re eligible. We’ll time it so there are no gaps.

Do Private PPOs use ACA tax credits?

No. Private PPOs don’t use ACA advance premium tax credits (APTC). Marketplace plans do, and those credits reconcile at tax time—under-reporting income can create payback.

How do I know if my doctors are covered?

Send your provider list. We check your doctors against the specific plan network you choose so you know before you switch.

How do we start?

Share your doctors, prescriptions, and budget. We’ll map options and enroll you quickly and compliantly.

This overview is educational, not tax or legal advice. Availability varies by state and carrier. Eligibility and enrollment subject to plan terms.

Lost Health Insurance?

Enrollment Guides • Special Enrollment

Lost Health Insurance? What to Do Next

Fast take: Losing coverage is stressful—but you have options. Most people qualify for a Special Enrollment Period (SEP) to enroll in a new plan. We’ll help you compare ACA vs. private PPO options, verify your doctors, and start coverage quickly.

Step 1: Assess your situation

Confirm why and when your coverage ends (job change, hours reduction, divorce, aging off a parent’s plan, etc.). Your reason sets your eligibility window and documentation needs.

Step 2: Talk to a licensed advisor

Health insurance has moving parts—networks, Rx tiers, referrals, and deadlines. A licensed advisor helps you avoid gaps and costly mistakes while matching plans to your providers and budget.

Step 3: Check eligibility for a Special Enrollment Period (SEP)

• Common QLEs: loss of employer coverage, COBRA ending, move to a new ZIP/state, marriage/divorce, birth/adoption, income changes.
• Timing: Most SEPs last 60 days from the event. We’ll confirm your exact window and effective date rules.

ACA Marketplace Plans

• Guaranteed acceptance.
• Potential income-based subsidies to lower premiums.
• Networks and deductibles vary—verify your doctors and Rx.

Private Medically Underwritten PPOs

• Often lower premiums for healthy applicants.
• Frequent nationwide PPO access—good for travelers.
• Underwriting applies; we pre-screen and confirm networks first.

Step 4: Consider COBRA vs. switching

COBRA keeps your employer plan temporarily but you pay the full premium (plus admin fee). We’ll run ACA vs. PPO vs. COBRA side-by-side so you can see total annual cost with your expected usage.

Step 5: Budget for healthcare costs

• Monthly premium and employer/COBRA contribution (if any).
• Deductible, copays, coinsurance, and maximum out-of-pocket.
• Prescription costs and prior authorization requirements.

Step 6: Secure new coverage—without gaps

Once we’ve confirmed eligibility and networks, we’ll submit your application, confirm your effective date, and set up online account access and ID cards.

Need help replacing coverage fast?

We’ll confirm your SEP window, verify your doctors and prescriptions, and place coverage quickly so you don’t go uncovered.

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Quick FAQs

Will I have a gap between plans?

Not if we align your application date with cutoff rules. Marketplace coverage often begins the 1st of the next month; some PPOs offer 1st or 15th start dates.

Can I switch off COBRA later?

Yes. You can switch during Open Enrollment or if another qualifying event occurs. We’ll time the change to avoid gaps.

Can you verify my doctors before I enroll?

Absolutely. Send your provider list (names & locations) and prescriptions—we’ll verify network participation and Rx tiers first.

For education only; eligibility, plan availability, and dates vary by state and carrier. Always review official plan documents.