Your Coverage & Care
Your Coverage & Care
 
Choosing the Right Coverage

Preparing for Open Enrollment

Depending on how you get your health insurance, open enrollment may last from a few weeks to a couple of months. Here’s what you should know as you consider your insurance options for the coming year.  

For All Types of Plans

  • Know the dates. The open enrollment period is for a specific time frame. Don’t assume that it will always occur during the same time period or last for the same amount of time. Always check with your employer or government programs for enrollment deadlines.
  • Consider all cost factors. All plans have deductibles, co-pays and/or coinsurance, premiums, formulary tiers and out-of-pocket maximums. You should consider total out-of-pocket expenses as you compare plans.
  • Know the network. Most plans have a network of preferred providers. The choice of providers – and the amount you pay to see your preferred providers – can change each plan year.  Don’t assume that your providers are still in network or accept your health insurance as you approach a new plan year. A provider may not participate in some plans offered by the same insurer (e.g. they may participate in the PPO plan but not the HMO plan).
  • Review coverage details carefully. Keeping the same plan doesn’t mean you shouldn’t review plan details.  A new plan year can mean new restrictions, new copay and coinsurance amounts and new formulary tiers.
  • Understand insurer processes. Medical necessity, prior authorization, benefit verification, step therapy and restrictions on using copay cards for drug deductibles are some of the insurer rules that affect what health services are covered and how much you pay.
  • Confirm that the plan is ACA-compliant. Plans offered through the Health Insurance Marketplace and by employers with 50 or more full-time employees are required to comply with the Affordable Care Act requirements. All ACA-compliant plans cover the ten essential health benefits with no annual or lifetime coverage maximums. 

For Employer-Provided Plans

  • Understand your flexible spending account policy. FSAs may have a grace period (2 ½ months after the plan year ends) to use remaining funds or a carryover provision (which allows you carry over up to $500 for the next plan year) – but not both. You may lose the unspent balance in an FSA if you leave a job.
  • Understand how high-deductible health plans and health savings accounts work. Some employers only offer this health coverage combination. While premiums are lower than other plan types, you will need to pay much more out of pocket before your insurer starts to cover expenses. You may want to compare total out-of-pocket expenses with your spouse’s or a health exchange plan if this is your only option. With health exchange plans, you may qualify for a premium subsidy.
  • Know your coverage date. If you’re a new employee, some employer plans begin coverage on your first day of work. Others begin as late as 90 days after your start date.  If there is a lag in when your insurance starts, you may want to consider a short-term plan to fill the gap.
  • Understand enrollment rules. Don’t assume that you don’t have to do anything if you want to keep the same plan.  For some employers, you need that confirm you are keeping the plan or your coverage may not continue. If you refuse coverage through your employer, you won’t have the chance to get it back until the next open enrollment period.
  • Understand how the COBRA works. COBRA stands for the Consolidated Omnibus Budget Reconciliation Act. This law allows employees to keep the health insurance that they would otherwise lose after quitting or being terminated from a job. It may be possible to keep the insurance for up to 18 months or longer. Having a chronic disease like arthritis means you shouldn’t be without insurance coverage. Ask your benefits manager how your premiums or benefits may change through COBRA.

Before choosing a plan: Discuss the pros and cons of each plan with your benefits manager.   If you can afford the fee, you may want to consult with a patient navigator, insurance broker or claims professional.

For Plans Provided Through the Health Insurance Exchange

  • Apply for a subsidy. Depending on your income, a subsidy could save you hundreds – even thousands– in monthly premiums.
  • Learn how to reduce your adjusted gross income (AGI). Insurance subsidies are based on your AGI. If yours is on the borderline for a subsidy, speak with a tax advisor on how to reduce your AGI.
  • Know the dates. Except for a few states that offer plans through state exchanges, everyone has the same open enrollment period, unless they have a special qualifying event.
  • Understand qualifying events. Events such as a marriage, divorce, change in residence, job loss or reduced income could qualify you for a special open enrollment period and another chance to find the best health plan for your arthritis care.  

Before choosing a plan: A licensed broker or a patient navigator with healthcare.gov can help you sort through the options. Other private organizations, including JOANY (Joany.com) and Stride Health (stridehealth.com) offer algorithms that can help you pick the best plans for your needs and even determine your overall costs. 

For Medicare Plans

  • Get a head start. Your first open enrollment for Medicare is three months before you turn 65. You’ll have a lot to consider so it’s best to get a head start on understanding how Medicare works.
  • Know the parts. Medicare has four parts: 
    • Part A covers medical insurance and Part B covers hospital insurance and physician-administered drugs. Also called Original Medicare, these benefits are managed by the federal government.
    • Part C  is also known as Medicare Advantage Plans. They provide Part A and Part B benefits. Coverage is managed by private insurers who contract with the federal government.
    • Part D is prescription drug coverage. If you decide not to get Medicare drug coverage when you're first eligible, you'll likely pay a late enrollment penalty unless you get drug coverage through a reputable source or you qualify for Medicare’s patient assistance known as Extra Help.
  • Consider a supplement. If you choose Original Medicare, consider a supplement (also called Medigap policy) to pay for expenses that are not covered. These policies are not available to people on Medicare Advantage plans.
  • No need to make payments yourself.  If you are receiving Social Security, premiums for Original Medicare, Medicare Advantage and Medigap are deducted from your Social Security check.

      Before choosing a plan: You can get personalized health insurance counseling at no cost to from your State Insurance Assistance Program (SHIP), www.shiptacenter.org. You can also find more information at medicare.gov. 

      For Medicaid Plans

      • Know your state requirements. Medicaid eligibility is based largely on income and income requirements vary by state.
      • Consider it for your children. All states have government-funded health insurance programs for eligible kids. Parents and expectant mothers may also receive benefits.

      Before choosing a plan: Contact your state Medicaid agency or apply through healthcare.gov. There is no open enrollment period for Medicaid; you can apply any time.

      If You Miss Open Enrollment

      Some plans don’t have a specific open enrollment period, but they don’t provide the benefits that ACA-compliant plans do. They include:

      Fixed indemnity plans. They pay a set (and usually small) amount for each doctor visit, prescription or day in the hospital, regardless of the cost. You pay the balance– which can be expensive.

      Short-term plans. Although these are typically offered for three months, in some states you can buy four policies back to back to get “coverage” for the entire year.  But the deductible starts over after each three-month period. A problem you develop during one three-month policy could potentially be considered a pre-existing condition in future ones.

      Health care sharing ministries. Offered as an alternative to health insurance, these programs allow individuals and families to pay into a pool used that is used to pay for participants’ health care costs. The types of costs covered are often very limited.  

      It’s important to note that none of these options typically pay for preventive care, mental health or pre-existing conditions. 

      For more help: Many insurers and brokers offer these plans. Carefully review plan benefits and restrictions before signing up.

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      arthritis foundation prescription for access