Dear Addy,
I know that open enrollment for health insurance begins Nov. 1, 2020. At the same time, I’m hearing about a Supreme Court case that could overturn the Affordable Care Act (ACA)! As a person with a bleeding disorder, what should I do about health insurance for 2021?
Signed,
Anxious About Insurance
Dear Anxious,
You are right that Open Enrollment is about to begin. Open enrollment is the period 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 for the coming year if it still meets your needs. Open enrollment dates vary, depending on the state you live in and whether you get your coverage from your employer, an ACA Marketplace, or another source – but for many people, open enrollment takes place annually in the fall.
You’re also right that there is a case currently pending in the Supreme Court that concerns the constitutionality of the Affordable Care Act. While this lawsuit is highly concerning (you can read more about it here), please know that the case does not affect your coverage or your protections, today or for your 2021 plan options. The ACA remains the law of the land for now. Furthermore, if you sign up for a health insurance policy during open enrollment, your policy will remain in effect through 2021 even if the Supreme Court (in a worst-case scenario) were to overturn the ACA. The bottom line? Use your opportunity during this fall’s open enrollment to get the health coverage you need for next year.
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 in most states the 2021 open enrollment period will run only from Nov. 1, 2020, to Dec. 15, 2020. However, 11 states have extended these deadlines. Click here for the deadlines in those states.
For people with Medicare coverage, open enrollment runs from Oct. 15 – Dec. 7, annually. The open enrollment period for Medicaid is 365 days a year, available to those who need it, whenever that occurs.
Scope of Coverage: When reviewing potential health 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 bleeding disorders product, and any other drugs you need, covered by the plan), and the provisions that describe claims and the payment of claims. The ACA requires that plans spell out insurance terms in easily understood language.
After reviewing any potential plan, you should be able to answer the following questions:
- What is the overall annual deductible?
- Are there separate deductibles for specific services?
- What is the annual 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 the plan doesn’t cover?
- Does the plan use a preferred drug list and, if so, will my product of choice be covered?
- Is my product covered under the pharmacy benefit or under the medical benefit?
If you cannot answer these questions, seek help and clarification from your company’s human resources department (for an employer-sponsored health plan), your HTC social worker, or an ACA Marketplace navigator (if you are selecting a plan via the Marketplace.)
Special Considerations for 2021 Plan Year: As you approach open enrollment this year, it is more crucial than ever that you carefully research your options. The COVID-19 pandemic, as well as decisions made in Washington, DC, in the past couple of years, are having complicated effects on insurance choices and 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.
- Additional insurers are joining the ACA Marketplaces (healthcare.gov) in many states. You may have new options for 2021 that you did not have last year.
- If you buy your insurance in the individual market, BEWARE of “skinny” plans and insurance look-alikes that don’t provide adequate coverage: short term plans, association health plans, fixed indemnity plans, and health care sharing ministries. These types of plans do NOT provide adequate coverage for people with bleeding disorders – and, unfortunately, many are widely advertised, often in very misleading terms. Make sure your plan meets ACA standards for coverage and financial protection, and don’t be duped by misleading sales pitches or look-alike websites. To avoid pitfalls, start your search on www.healthcare.gov.
- As you compare plans on healthcare.gov, remember that you may be eligible for assistance with your premiums and/or copays. Most people who buy their insurance on healthcare.gov qualify for tax credits to help them with their monthly costs!
- Watch out for health plans that limit your ability to make use of manufacturer co-pay assistance programs. Health plans with accumulators do not credit manufacturer co-pay assistance toward your overall deductibles or out-of-pocket maximums, leaving patients on the hook for out-of-pocket costs up to their yearly maximum. Unfortunately, it can be hard to spot whether your plan contains an accumulator adjuster. Read your plan documents carefully and call plan administrators to ask specific questions. Learn more about accumulator adjusters in this recorded session from HFA’s 2020 Symposium.
- Have you experienced employment changes, due to COVID or otherwise, that impact your health coverage? Please check out this resource created by HFA and NHF outlining possible options. Some additional considerations:
- If you lost your job in 2020 and opted to continue your job-based coverage under COBRA, you may wish to explore whether it makes sense to switch to a Marketplace plan for 2021. Start your research on www.healthcare.gov.
- If you experience job loss this fall, make sure you arrange for insurance that will cover you for the remainder of 2020, whether through COBRA or through special enrollment period coverage via the ACA Marketplace. Coverage that you obtain during open enrollment will only go into effect on January 1, 2021.
A reliable resource for information on open enrollment for 2021 individual insurance plans can be found here and a detailed set of FAQs (including many in Spanish) can be found here.
Please be an active participant as you consider your insurance options for 2021! 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.
Sincerely,
Addy
