If your employer open enrollment is coming up, you may be tempted to either auto-renew last year’s plan without thinking about it, or to wonder if you’d be better off with something outside of work. Both reactions are common. Both can also leave money or coverage on the table.

For a lot of families, the employer plan is the right answer, sometimes by a wide margin. The trick is knowing how to read your enrollment packet so you can tell whether your work plan is genuinely a good deal, or whether it might be worth comparing other options.

What Is Employer Open Enrollment?

Open enrollment is the window your employer sets each year, usually two to four weeks long, when you can sign up for benefits, change your plan, add or drop dependents, and adjust contributions to things like an HSA or FSA. Most employers run it in October or November, with new coverage starting January 1.

It’s typically the only time of year you can make these changes without a “qualifying life event” like marriage, the birth of a child, or loss of other coverage. Whatever you decide during open enrollment usually locks in for 12 months.

Why You Should Review Your Employer Plan Every Year

Even if last year’s plan worked fine, premiums, deductibles, and prescription coverage often change behind the scenes. According to KFF’s 2025 Employer Health Benefits Survey, the average annual premium for employer-sponsored family coverage reached nearly $27,000 in 2025, with workers contributing about $6,850 of that out of pocket. Reuters covered the same shift as a national story.

And it’s not slowing down. Mercer is reporting that employers are bracing for the highest health benefit cost increase in 15 years going into 2026. A lot of plans are being redesigned this open enrollment season, sometimes with higher employee contributions, sometimes with bigger deductibles. Reviewing your packet matters more this year than last.

When Your Employer Plan May Be the Best Option

The clearest case is when your employer pays a large portion of the premium. If your company picks up 70%, 80%, or more of the family premium, the math is hard to beat. Private health insurance doesn’t come with an employer subsidy, so even a great private PPO can’t compete on cost when half (or more) of your monthly premium is covered by someone else.

Another is when the plan benefits themselves are strong. A reasonable deductible, modest copays, and a manageable max out-of-pocket. That combination is often more valuable than people realize.

Pre-Existing Conditions and Ongoing Care

If you, your spouse, or a child is currently being treated for something significant, the employer plan is almost always the right place to be. Pre-existing conditions, ongoing therapy, recent surgeries, chronic conditions like diabetes or autoimmune disease, frequent specialist visits. Job-based coverage is guaranteed-issue. They can’t deny you, and they can’t price your premium based on your medical history.

Many private health insurance plans, by contrast, do medical underwriting, which means a complex medical history can affect what you qualify for. If somebody in your family is mid-treatment, this isn’t the year to roll the dice.

Expensive Medications and Prescription Coverage

Medications are one of the most common places people get surprised. If anyone in your family takes specialty drugs, biologics, injectables, brand-name medications, insulin, or anything billed in the thousands per month, the employer plan’s drug formulary is your best friend.

Before you change anything, look up every prescription on your current plan’s formulary and confirm what tier each drug is on. Then check the same drugs on any plan you’re considering. The difference between a Tier 2 generic and a Tier 4 specialty drug can be hundreds or thousands of dollars per month.

Maternity, Pregnancy, and Family Planning

If you’re pregnant or planning to be soon, employer coverage is usually the better path. Maternity is one of the ten essential health benefits required on all employer plans and on the ACA Marketplace. Many private health insurance plans treat maternity differently, and some exclude it entirely. This isn’t the moment to compare on premium alone.

If a pregnancy is on the horizon for the coming year, it should weigh heavily in your decision.

Why Dental and Vision May Be Worth Keeping Through Work

Dental and vision are often the easiest “yes” on an employer benefits packet. Premiums are usually low, sometimes under $30 a month, and the coverage is decent.

If you already have dental and vision through work, it’s usually worth keeping. You’ve already gone past any waiting periods for major work like crowns, root canals, or orthodontics. Switching to a new individual plan often resets that clock and starts you back at zero, which can mean waiting six to twelve months before a needed procedure is covered.

When It May Make Sense to Compare Private Options

Now the other side of the coin. There are real situations where comparing private health insurance makes sense.

The most common: your employer covers your individual premium well, but adding a spouse or children is expensive. This is sometimes called the “family glitch” or just spousal-tier sticker shock. If adding your family to the work plan would cost an extra $1,200, $1,500, or $2,000 per month, it’s worth seeing whether a separate private PPO for your spouse and kids comes in lower.

Other situations where private is worth comparing:

• The whole family is healthy and unlikely to hit the deductible
• You don’t qualify for ACA Marketplace subsidies because your employer offer is considered “affordable” under federal rules
• You want private PPO flexibility, especially if you travel or split time between states

A licensed agent can run the numbers side by side. Sometimes the right answer is to keep the employer individual coverage for the employee and put the spouse and kids on a separate private plan. Sometimes everyone stays on the work plan. The only way to know is to compare them honestly. If you want background on why PPO options have become harder to find specifically on the ACA Marketplace, we wrote about that here: Why Your Marketplace Plan May Not Offer a PPO Option.

What to Review Before Making a Decision

Open enrollment is more than just looking at the monthly premium. The Kiplinger guide on choosing a health plan recommends running through this list, and it’s the same one a good agent would walk you through:

• Monthly premium (what comes out of your paycheck)
• Deductible (what you pay before insurance kicks in)
• Copays and coinsurance (what you pay at the doctor or pharmacy)
• Max out-of-pocket (the worst-case ceiling for the year)
• Prescription coverage (formulary tiers for every drug your family takes)
• HSA eligibility (whether the plan qualifies for tax-advantaged savings)
• Total yearly cost (premium plus likely out-of-pocket spending combined)

That last one is the one most people skip. A “cheaper” plan with a higher deductible can easily cost more by year-end than the slightly more expensive plan with better coverage. The total picture is what matters.

Worth noting too: the federal rules around job-based coverage and Marketplace subsidies have specific affordability tests. If your employer offer is considered affordable under those tests, you (and your family) may not qualify for ACA premium tax credits even if you opt out. HealthCare.gov walks through this directly.

If your situation is the opposite (you’re self-employed and don’t have an employer plan to weigh at all), we wrote separately about that here: How Self-Employed People Can Save Thousands on Health Insurance.

Final Thoughts

Employer coverage isn’t automatically bad. Private insurance isn’t automatically better. The best plan is the one that fits your family’s medical needs, your budget, your medications, and the total yearly risk you’re comfortable carrying.

For most families with someone going through active care or a working spouse covered by a generous employer plan, staying with the work plan is usually right. For families paying $1,500+ a month to add dependents, healthy enough to qualify for private underwriting, and looking for PPO flexibility, comparing privately is worth the half-hour conversation.

If your employer open enrollment is coming up and you’re not sure whether to keep your work plan or compare other options, I can help you review the full picture. We can look at the monthly cost, deductible, max out-of-pocket, prescriptions, and whether it makes sense to keep everyone together or compare separate options for a spouse or dependents.

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Thyrza Mariano Amorim de Oliveira is a licensed health insurance agent. NPN: 21702538. Licensed across multiple states; verify any agent on the National Insurance Producer Registry.

Sources & Further Reading

• KFF, 2025 Employer Health Benefits Survey — kff.org
• Mercer, Employers prepare for the highest health benefit cost increase in 15 years — mercer.com
• HealthCare.gov, Job-based health insurance and Marketplace options — healthcare.gov
• Reuters, U.S. health insurance premiums rose to $27,000 for families in 2025 — reuters.com
• Kiplinger, Find the Right Health Plan During Open Enrollment — kiplinger.com