The January Question Wave: What Employees Ask When a New Plan Year Starts, and How Brokers Can Prepare
Every change made at renewal comes back as a question in January. What employees ask in the first weeks of a new plan year, who ends up answering, and how brokers can prepare clients before January 1.
The January question wave is the stretch at the start of a new plan year when employees use their benefits for the first time under new terms, and every change made at renewal comes back as a question. On a calendar-year plan, deductibles and out-of-pocket maximums reset on January 1, new ID cards go into use, formulary and network changes take effect, and new payroll deductions show up on the first paycheck. The questions land on HR first and on the broker's service team next. Most of them are predictable, which means most of them can be prepared for in November and December.
Most employer plans start their plan year on January 1, so for most advisors this happens across a large part of the book in the same few weeks. Groups with off-cycle plan years go through the same thing on their own start date.
Why do employee benefits questions spike in January?
Open enrollment is a decision. January is the first time anyone uses that decision.
Elections made in November, some of them carefully and many of them in a hurry or by default, meet the pharmacy counter, the doctor's front desk, and the paycheck within days of each other. Three things stack up at once. Annual amounts reset to zero. Changes approved at renewal take effect. And employees who didn't read their enrollment materials, which is a lot of them, find out what changed by running into it.
None of this is a sign that the renewal went badly. A plan can be well designed, well priced, and clearly communicated, and January will still produce a wave of questions, because the questions come from use, and use starts on January 1.
What do employees ask about in the first weeks of a new plan year?
The questions fall into a handful of groups, and they tend to arrive in roughly the same order.
ID cards and the pharmacy
When a group changes its carrier, administrator, or pharmacy benefit manager, employees get new ID cards. Pharmacies often keep the old member information on file, so the first refill of the year can be rejected at the counter until someone updates it. If cards haven't arrived by early January, employees need to know how to get a temporary card or their member ID from the plan's portal or member services line.
Deductibles and out-of-pocket maximums that reset
On a calendar-year plan, the deductible and the out-of-pocket maximum both start over on January 1. An employee who met their deductible last fall may have paid very little for care in November and December, and then pays much more for the same visit or prescription in January. On a high-deductible plan paired with a health savings account, most care and most prescriptions cost the full negotiated rate until the deductible is met, preventive care aside. This is one of the most common January questions, and one of the easiest to explain ahead of time.
Formulary changes and prior authorizations
Pharmacy benefit managers update their formularies regularly, and many changes take effect at the start of the plan year. A drug can move to a higher tier, pick up a step therapy requirement, or drop off the formulary. When a group changes pharmacy benefit managers, existing prior authorizations may need to be resubmitted. Employees on maintenance medications feel these changes first, often at their first refill of the year.
Network changes
A carrier change or a narrower network can mean a doctor an employee has seen for years is out of network on January 1. Many plans offer a transition or continuity-of-care process for people in the middle of treatment, but employees rarely know to ask for it until after a bill arrives.
Payroll deductions
New contribution amounts take effect on the first January paycheck. When the deduction doesn't match what an employee thinks they elected, that's an HR question, and it usually comes in the first pay cycle.
Flexible spending and health savings accounts
New flexible spending account elections start over for the new year. For last year's balance, a plan can offer either a grace period of up to two and a half months or a limited carryover, but not both, along with a run-out period for submitting last year's claims. Employees often don't know which one their plan uses. Health savings account contribution limits change every year, and employees newly enrolled in a high-deductible plan may need to open an account before contributions can start.
Explanations of benefits and the first bills
An explanation of benefits arrives weeks after a visit, and many employees read it as a bill. When the first EOBs of the year show a higher patient responsibility because the deductible reset, a second round of questions starts, usually in late January and into February.
Who ends up answering January's questions?
Most groups never decide. The questions go to whoever the employee knows to ask.
That's usually HR. HR can handle payroll deductions and eligibility, because HR owns them. Questions about cards, claims, and networks belong with the carrier or administrator's member services team. Pharmacy questions belong with the pharmacy benefit manager. Questions about why the plan changed belong with the broker, because the broker made the recommendation and can explain it.
In practice, a lot of those questions skip their natural owner and land on HR, and then on the broker's account manager or service team, because those are the people the employee or the HR lead already trust. That trust is a good thing. It also means the advisor's service team absorbs much of January's volume, in the same weeks it's closing out renewal season.
How long does the January wave last?
For most groups, the heaviest stretch is the first several weeks of the plan year, as employees fill their first prescriptions and make their first visits. A second, smaller rise often follows as explanations of benefits and bills catch up with early January care. By late February, most groups are back to a normal pace.
Off-cycle groups follow the same pattern on their own plan year start. A group that renews July 1 has its own wave in July and August.
How can brokers prepare clients before January 1?
Most of the preparation uses information the advisor already has from the renewal. A practical sequence for November and December:
- 1Pick the groups with the most change going into January 1. A new carrier or administrator, a new pharmacy benefit manager, a deductible increase, a narrower network, or a new plan option are the changes most likely to produce questions.
- 2For each of those groups, write a one-page summary of what changes on January 1 in the words an employee would use. Not the committee's version. "Your deductible starts over on January 1" is more useful than a benefit grid.
- 3Confirm when new ID cards will be mailed and how employees can get a temporary card or member ID if theirs hasn't arrived.
- 4Ask the pharmacy benefit manager for its disruption report on formulary changes, and make sure the HR lead knows roughly how many employees are affected before the first refills of the year.
- 5Agree with the HR lead on who answers which kind of question, and put the member services numbers where employees will look for them.
- 6Put a short check-in on the calendar for about two weeks after January 1, to see which questions are coming in and whether the routing is holding.
What should the employer's HR team have ready before the plan year starts?
The HR lead will field the first wave, so it helps to have a short kit in place before the holidays. That includes the member services number and portal link for each carrier or administrator, the process for temporary ID cards, the one-page summary of what changed, the Summary of Benefits and Coverage for each plan, the flexible spending account deadlines and carryover or grace period rules, and a named contact on the broker's team for anything that needs escalating.
None of this is complicated. Most of it already exists somewhere in the renewal file. The work is getting it in front of the right person before January 2.
Where Kio fits
Kio, from KindHealth AI, is live, and it's there for employees this enrollment. If you're an advisor and want to talk about it for one of your groups, start here. To see Kio from the employee's side, visit the Kio page.