Selecting the Best Coverage for Your Arthritis Care: Open Enrollment Checklist

Use this checklist to make sure you get the best plan for your healthcare needs.

  • Health Expense Audit. Review all expenses from the previous year (premium, copays, deductibles and out-of-pocket payments for covered and non-covered services). Then, calculate estimated expenses for the new plan year. Discuss potential changes in your treatment plan for the upcoming year with your doctor before calculating estimated expenses.
  • Financial Assistance Audit. Review all financial support you received from the previous year and look for new programs. Keep track of application deadlines and check the criteria to make sure you qualify. You should find out if the financial assistance applies to your deductible or out-of-pocket maximum. For example, many arthritis patients use co-pay assistance, such as co-pay cards or manufacturer coupons, to pay for their life-saving medications. Pharmacy Benefit Managers (PBMs) and insurers increasingly use co-pay accumulator programs to prevent such assistance from counting towards patient cost-sharing, such as their deductible or annual out-of-pocket maximum.
  • Benefit changes. Review the summary of benefit for coverage changes from the previous year (office visits, prescription drugs, hospital or lab services, preventative health, physical and occupational therapy, mental health services, durable medical equipment and other benefits). Paying the same monthly premium as the previous year doesn't mean that the same benefits are covered or at the same level. For example, your physical therapy coverage may change from 12 visits per year to three visits per year. Never assume that premiums, deductibles, copays and coinsurance are the only differences between plans, even when the plan is offered by the same company. The COVID-19 pandemic may affect your health plan's benefits as well, and may include expanded coverage for a limited time for services such as telemedicine.
  • Premium and deductible. Check for changes in your monthly premium and/or annual deductible (i.e. individual and family deductibles). Keep in mind that you may have separate medical care, drug and durable medical equipment deductibles.  Usually, a lower premium means a higher deductible. 
  • Copay and coinsurance. Check for changes in copayments or coinsurance (the percentage you must pay for services) for your most commonly used services and products and well as for emergency and hospitalization services.
  • Drug formulary. Make sure the drugs you take are on your plan’s formulary and check which tier they are on. Your primary arthritis drug may be moved to a higher tier and that means you may pay more money out of pocket.
  • Provider network. Never assume that your providers are still in-network even if the plan is offered by the same insurer. Always ask your provider’s office to confirm, because sometimes the insurers’ online directory may not be up to date.  Keep in mind that a provider is not automatically in-network for all the plans that an insurer provides.  For example, a provider may participate in the insurer's PPO plan but not the HMO plan  You will also need to confirm the in-network pharmacies and lab facilities.  
  • ACA compliance. Check whether available plans cover hospitalization, maternity and newborn care, preventive services, mental health and substance abuse treatment and other requirements of the Affordable Care Act. If not, you’ll need a plan through a state or federal exchange if you need these services. If your income falls below certain limits you may be eligible for a subsidy to reduce the premium on an exchange plan.
  • Flexible Spending Account.  Check if your employer offers an FSA. Find out the grace period and rollover policy so you don’t lose unspent balances.
  • Health Incentive Programs. Find out whether your employer offers a financial incentive for good health practices e.g. exercise, healthy eating and weight management. These monies can be applied to out of pocket expenses.
  • Spouses and dependents.  If your spouse, dependents or adult children under age 26 are currently covered through your employer-sponsored plan, make sure that your employer is still extending coverage to these beneficiaries. Also, see if your employer has changed the amount they’ll contribute toward dependents’ monthly insurance premiums. If your spouse’s employer offers insurance, compare costs and benefits with your current plan.

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