Summer is over and already it is time to start making your list and checking it twice. No, not that list; the list of the things you need to make sure your health insurance plan covers when your open enrollment period starts. An open enrollment period is the time when individuals can enroll themselves and any dependents in Qualified Health Plans for the following year. Open enrollment usually lasts about 30 days. The first step is knowing when your open enrollment period is; the second is finding the right plan.
The Affordable Care Act (ACA) requires insurance companies to provide an easy-to-read chart of benefits for any plan it offers. This is great for the general benefit items, but for patients with chronic conditions, it is the details that count. For example, bleeding disorder patients around the country have found that their hemophilia treatment center (HTC) is in the network of providers their insurance will cover only to learn that the doctor they see at their HTC is not. In addition, many insurance companies now are limiting pharmacy choice for patients, and moving factor from major medical coverage to pharmacy coverage. This allows them to charge a percentage for the cost of factor (20-50%) verses a copay.
This is not all. Though the ACA capped annual out-of-pocket costs, some patients have to pay the full out-of-pocket limit in the first month that the insurance policy is effective. For example, the out-of-pocket maximum for an individual is $6,600 individuals and $13,200 for a family. Already, patients with chronic diseases in California are reaching their out-of-pocket maximums in one month and they can’t afford to pay. Legislation is in the works to allow California residents who reach the out-of-pocket max quickly to pay down the balance over 12 to 24 months. Until this legislation and legislation like it around the country becomes law, many individuals and families are at risk for financial hardships should they reach their limit too quickly.
If you are not sure, now is a good time to learn when your open enrollment starts and ends. It is typical to have a 30 day window, often in the Fall. Check with your human resources department, if you can. Some open enrollment dates to keep in mind:
- Marketplace plan coverage starting in 2015: November 15, 2014- February 15, 2015
- Medicare plan coverage starting in 2015: October 15 – December 7, 2014
- Medicaid and CHIP are open 365 days a year
Important Things To Know Before Signing Up:
https://www.youtube.com/watch?v=AXAoIGR1uhc
So what can you do? How do you find out if the policy you are considering is the right one? How do you plan for reaching out-of-pocket limits quickly? The checklist on below can help you determine whether the insurance plan you have in mind has what you need to meet your health insurance coverage needs for the coming year.
- Create a list of the benefits you need. List the services you used in the past year, then think about what services you may need in the coming year. This includes use of your health care providers such as doctors and physical therapists, specialists, your HTC, your hospital, your prescription drugs, and other treatments you feel your family is likely to need. Don’t forget about optical care and dental care!
- Create a list of the benefits you need. List the services you used in the past year, then think about what services you may need in the coming year. This includes use of your health care providers such as doctors and physical therapists, specialists, your HTC, your hospital, your prescription drugs, and other treatments you feel your family is likely to need. Don’t forget about optical care and dental care!
- Invest the time to review plans in detail. Allocate time to reviewing the plans to which you have access. Read the plan options carefully but don’t be afraid to ask questions about the plan. Contact your human resources person for help if you have a private plan through your employer, call your insurance provider if you have a self-insured plan, or call 800-318-2596 if you are looking at Marketplace plans.
- Check your healthcare providers. Verify that your regular healthcare providers, HTC, clinics, and hospitals are in-network. Remember, your HTC may be in-network but the doctor you see there may not. Look carefully at the details. Call your healthcare provider to find out if they are in-network under any plan you consider.
- Check your pharmacy or specialty pharmacy. Like healthcare providers, pharmacies contract with insurers to provide medication and related services. You may have a specialty pharmacy, home care, or 340B pharmacy that you prefer. It is important to check if they are in-network under the plans you consider.
- Know the rules. Find out if you need prior approval to see a specialist. Many health plans require that you get advance permission, called “certification,” in order to have tests, procedures, or surgery that a doctor recommends.
- Explore discounts. Health plans may offer discounts for services like dental care or eyewear. These programs aren’t insurance but they can offer savings on services your family needs, and these discounts can add up. You might be able to balance these discounts with out-of-pocket costs.
Once you make a decision, obtain a copy of your Certificate of Coverage, which provides a detailed explanation of your plan’s health benefits in your plan. Review this carefully and keep it in a safe place as a reference.
In summary, to choose a health plan wisely, think through your needs, build a budget, do your homework, and seek help in making your selection. You are going to be stuck with the plan you choose for 365 days; do all you can to make sure you get everything on your list.
English 
Español