Open Enrollment: It’s that time of year again! 

Open enrollment is the period every year when health insurers are required by law to accept applications from new enrollees regardless of their health history. This is also when consumers can stay with their plan or switch to another.

Open enrollment dates vary depending on the state you live in. Whether you get your coverage from Medicare, an ACA Marketplace, an employer, or other sources – most often, open enrollment occurs in the fall.

It is critical for consumers with high-cost conditions like bleeding disorders to be an active participant during open enrollment.  Even if you are happy with your current plan, do not assume it will remain the same—plan terms frequently change yearly! If you auto-renew coverage and do not research your health insurance options for 2025, you could be left without access to your drugs or providers or hit by surprise with unexpected and unaffordable out-of-pocket costs.

Timing

The most important thing to remember about open enrollment is when it starts and ends.  If you miss the open enrollment period, you can only sign up for coverage if you have a “qualifying life event” that creates a particular enrollment period (typically 60 days). Qualifying events are significant life changes like marriage/divorce, childbirth/adoption, losing coverage, moving to another state, etc.

If you get health insurance through your job, check with your human resources department to determine when open enrollment will begin.  

For Medicare, open enrollment runs from October 15th to December 7th.  Medicare will extend open enrollment by two months for those impacted by Hurricane Helene or Milton. Most states have open enrollment in ACA Marketplaces from November 1st to December 15th.  These dates can vary slightly among the 19 states operating their own ACA Marketplaces.  For example, Idaho runs from October 15th- December 15th, while states like California, New Jersey, New York, and Rhode Island extend enrollment through January 31st.  You can check www.healthcare.gov to confirm open enrollment dates in your state.  However, in any state, you must enroll by December 15th for coverage to be effective January 1st.  

Enrollment in Medicaid or State Children Health Insurance Programs (SCHIPs) is open yearly.

Cost

Don’t focus only on premiums!

When shopping for health insurance, it is always important to consider all out-of-pocket costs.  Plans with higher premiums typically have lower annual deductibles and out-of-pocket spending limits.  For persons with costly conditions like bleeding disorders, these lower cost-sharing limits can make a massive difference in the total expense of your plan.

When shopping on www.healthcare.gov, don’t be put off by “list” prices. Enhanced premium tax credits are still available to all Marketplace consumers through 2025, limiting premium costs to 8.5 percent of income.  The enhancements to the ACA’s premium tax credits were created by the federal American Rescue Plan Act of 2021 and have made Marketplace plans dramatically more affordable to consumers (lowering the cost of a “silver” plan to less than $10/month for many consumers).

Scope of Coverage

When shopping for coverage, make sure to read all plan provisions carefully. 

For people with bleeding disorders, it is critical to research whether their products are covered under the plan’s drug formulary and whether their physicians and providers are within the plan’s network.

Beware of copay accumulator adjusters! These are often buried in hundreds of pages of plan documents, called all kinds of beneficial-sounding names like “copay protection programs,” and can be very difficult to find (even with the help of insurance experts).  However, they can deny you any benefit from the copay assistance you may need to afford your medications.  

For ACA Marketplace consumers, a list of participating insurers with copay accumulator language in plan documents can be found here. Ask the insurer directly if copay accumulator adjusters will be applied for other consumers and get a written response!  

If you are enrolled in large employer or self-funded coverage, beware of alternate funding programs through third-party vendors. Third-party vendors (like Payer Matrix, Prudent Rx, or ShaRx) exclude coverage of specialty drugs and force consumers to enroll in manufacturer copay assistance programs for which they otherwise would not be eligible.  AFPs are the latest scheme by insurers to capture the full copay assistance intended for consumers needing high-cost drug therapies.

For help with these issues, you can contact your company’s human resources department (for an employer-sponsored health plan), hemophilia treatment center social workers, or health insurance navigators available through www.healthcare.gov (if you select a plan via the Marketplace.)

What’s New for 2025?

• Thanks to the Inflation Reduction Act of 2022, enrollees in Medicare Part D plans will, for the first time, have their out-of-pocket drug costs capped at only $2,000 per year.
• DACA recipients (children of undocumented immigrants or “Dreamers”) will be eligible to use the ACA Marketplace.
• Additional state-funded subsidies are expanding for residents of California and New Mexico.
• Consumers will no longer be able to buy short-term limited benefit health insurance lasting more than 3-4 months, depending on renewability.  These types of “junk” or “skinny” health plans do not provide adequate coverage for persons with costly conditions like bleeding disorders, and those who enroll in them lose access to ACA premium tax credits and most (if not all) consumer protections under the ACA (including coverage of essential benefits and annual cost-sharing limits).  To avoid this, always start your search on www.healthcare.gov.

Resources

ACA Open Enrollment 2025 Guide | healthinsurance.org

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 2022! Whether you keep your current health insurance or 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.