US healthcare is a four-party arrangement since employers are also intermediaries. Employers select the plan (or plan options) and they pay the bulk of the premiums. Their check is always bigger than yours even if you pay more for your policy than they do. As such, most of the sales effort by health insurance companies is directed at the employer and they exercise a lot of judgment. In contrast, I have never once spoken to a representative of the health insurance company during open enrollment, it is always HR.