I’m applying for health insurance for the first time this open enrollment period. With a bleeding disorder, what should I look for in an insurance plan?
The Open Enrollment Period is a timeframe each year when health insurance plans or HMOs (health maintenance organizations) are required by law to accept applications from new plan enrollees regardless of their health history. This also is the time when you can choose to stay with your existing health plan if it is the right one for you. Generally, open enrollment is held once a year, typically in the fall (the exact dates will vary depending on where you get your insurance coverage: from your workplace, from an ACA Marketplace, etc.).
Use this outline to help you select a plan during open enrollment:
Scope of Coverage. When reviewing potential health insurance plans (and when considering whether to renew your existing plan), it is important to review all plan provisions carefully. You will want to closely read the “general provisions” (length of policy, types of providers you can see, term definitions), the “drug provision” (is your factor product, and any other drugs you need, covered by the plan), and the provisions that discuss claims and the payment of claims. Federal law requires health plans to spell out all these terms, plus many others, in easily understood language.
After reviewing any potential plan, you should be able to answer the following questions. If you can’t, contact your company’s human resources department, your HTC social worker, or a Marketplace navigator if you are selecting a plan via the Marketplace.
- What is the overall deductible?
- Are there separate deductibles for specific services?
- What is the out-of-pocket limit on my expenses?
- What is not included in the out-of-pocket limit?
- Is there an overall annual limit on what the plan pays?
- Does the plan use a network of providers? Are my key providers (hematologist, specialty pharmacy, etc.) in-network? What do I pay for out-of-network care?
- Do I need a referral to see a specialist?
- Are there any services this plan doesn’t cover?
- Does the plan use a preferred drug list and, if so, will my product of choice be covered?
Timing. If you get insurance through your job, check with your human resources department to find out when your company’s open enrollment period begins and ends. If you get your health insurance through the ACA Marketplace, please note that the 2018 open enrollment period will be significantly shorter this year than in prior years: open enrollment will run from November 1, 2017, to December 15, 2017. For people with Medicare coverage, open enrollment runs from October 15 – December 7, annually. The open enrollment period for Medicaid is 365 days a year, available to those that need it, whenever that occurs.
Special Considerations for 2018 Plan Year. As you approach open enrollment for 2018, if you buy your own coverage on the individual insurance market, it is more crucial than ever that you carefully research your options and DO NOT simply auto-renew your existing Marketplace insurance plan. Decisions made in Washington, DC, in the past few months are having complicated effects on insurance costs, so you will have to take extra care to evaluate your options to pick the plan that offers you the best and most affordable coverage.
Here’s a key example. You may have heard that President Trump’s administration has decided to stop paying cost sharing reductions (CSRs) owed to insurance companies under the ACA. These federal payments are meant to reimburse insurers for the discounts the insurers have to grant to qualifying enrollees with respect to their out-of-pocket costs (copays, deductibles, etc.).
What is the impact of this policy change? If you have a Marketplace plan and currently receive assistance with your deductibles and copays, that assistance will continue for the rest of 2017. Insurers are required by federal law to continue giving these discounts. Looking ahead, the policy change means that premiums for 2018 Marketplace plans will rise sharply (insurers will fold the cost of the unpaid CSRs into their prices), BUT:
- If you get a subsidy to help purchase insurance on the Marketplace (“advance premium tax credits,” or APTC), the amount of your subsidy will also increase, protecting you from the rise in premiums.
- If you are entitled to CSR assistance with your out-of-pocket spending, and you purchase a qualifying Silver plan, you will continue to receive that CSR assistance in 2018.
- If you qualify for APTC subsidies but not for CSR assistance, you should broaden your comparison shopping during Open Enrollment: for example, in some states, Gold plans (with lower out-of-pocket spending amounts) may be a cheaper option than Silver plans for 2018.
- If you don’t qualify for APTC subsidies to help pay for your premiums, you should investigate your options among off-Marketplace plans (in most states, the costs of the unfunded CSRs are loaded onto Marketplace plans only).
Please be an active participant as you consider your insurance options for 2018! And whether you choose to keep your current health insurance or to enroll in a new plan, READ YOUR POLICY. This is critical because the health insurance plan you choose will be yours for 12 months unless you have a qualifying life event that allows you to switch plans.
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HFA frequently receives questions from the bleeding disorders community related to advocacy issues. The questions often impact the entire community. In an effort to reach the largest audience possible with our responses to these widely applicable questions, HFA developed “Dear Addy.” Questions submitted to this column are edited in order to protect privacy and should be considered educational only, not individual guidance.