Editor’s Note: We are rapidly approaching the period of open enrollment for Medicare, the Marketplace and Medicare Advantage. This article first appeared in Pathlight, the flagship magazine of the Pulmonary Hypertension Association (PHA), and offers an overview of what you need to know about Open Enrollment. Learn more about Pathlight and how to get your own copy here.

What Is Open Enrollment?

Health insurance plans limit when customers can enroll or make changes to their coverage. During most of the year, changes and additions are restricted to major life events such as losing a job, getting married or divorced, having a child, or adopting.

Open enrollment, or annual enrollment, is a period of time each year when anyone can change their existing coverage. When an open enrollment period takes place depends on the source of the health insurance.

Employer-provided insurance must provide information about its annual enrollment period to all employees. Medicaid open enrollment dates for 2020 vary by state, but most open by Nov. 1. More information and links to state programs are available at healthcare.gov. For those covered by Medicare or who purchase health insurance through a state or federal insurance marketplace, the annual enrollment period begins this fall.

Health insurance plans change premiums and benefits from one year to the next, so open enrollment is an important opportunity to review benefits and ensure the coverage selected will continue to meet the policyholder’s needs in 2020.

Questions to Consider When Selecting Coverage

These questions can assist with comparing and contrasting coverage options:

  • What is the premium or monthly cost I would pay to maintain this health insurance?
  • Will I have to pay a deductible or initial amount before coverage begins? If so, how much is the deductible?
  • Does the health insurance I am considering include prescription drug coverage or would I need to purchase that separately?
  • What medications do I expect to take in the upcoming year? Are these medications included in the health plan’s formulary or covered-drug list? If there are generic versions of my pulmonary hypertension (PH) therapy, is the variation I need covered?
  • Am I likely to need routine tests or hospitalization in the upcoming year?
  • How much of the total cost of my anticipated medical care and prescriptions will this plan cover? (For example, for each of your PH medications will you be charged a set dollar amount called a copay, or will you be responsible for a percent of the drug price, which is called a co-insurance?)
  • Does the pharmacy network for this plan include the specialty pharmacy that delivers my PH medications?

Finally, take a second look at the premium or monthly cost for each plan option. Plans with more expensive premiums may cover more services or cover more of the cost, making them a better deal in the long run.

Open Enrollment Obstacles

When choosing coverage, individuals with PH should be cautious of short-term plans and plans with copay accumulators. Coverage of PH therapies with generic alternatives can also vary dramatically from plan to plan.

Short-term, limited duration health insurance plans are inexpensive plans designed to provide coverage during an emergency for someone who is experiencing a temporary gap in health insurance coverage from another source. Short-term plans are not required to provide essential health benefits. When considering a short-term plan, read the fine print to make sure coverage is provided for hospitalization, prescription drugs and preventative screenings, none of which are required by law.

The copay accumulator model is a cost-shifting strategy in which health insurance plans do not apply manufacturer copay cards or other financial assistance to an individual’s deductible or out-of-pocket maximum. This model is most common in commercial plans but has also been showing up in some Medicare Advantage plans.

Individuals taking a PH therapy for which there are generic equivalents should review their plan formulary carefully to ensure they will have the coverage they need. More information about access to brand and generic PH therapy is available at PHAssociation.org/Genericsfyi.

Get Help Choosing the Right Plan

Several nonprofit organizations offer one-on-one assistance with selecting health insurance coverage:

Patient Advocate Foundation

PAN Foundation

Medicare Rights Center

In addition, many PH medical teams include someone knowledgeable about the pros and cons of different insurance types. If you are not able to get the help you need from one of these organizations, consider asking your nurse or doctor if there is someone available to help you determine what you are eligible for and which health insurance plan might work best for you.

PHA’s Treatment Access Program is here to help. If you have additional treatment access concerns that are not covered in this article, contact PHA at 301-565-3004 x749 or gro.noitaicossAHP@ecnarusnI.

Below is a summary of information for enrolling in Medicare, the Marketplace and Medicare Advantage:

Medicare Open Enrollment
Oct. 15 – Dec. 7, 2019

Coverage starts: Jan. 1, 2020

What you can do:

  • Switch from one Medicare Part D plan to another.
  • Switch from Original Medicare to an Advantage Plan, from an Advantage plan back to Original Medicare, or between Advantage plans.
  • Enroll in a Medicare Part D plan if you missed your initial enrollment period. (A late-enrollment penalty may apply.)
  • Make multiple plan changes during this time without penalty.

Where to start:  Medicare.gov/find-a-plan

Marketplace Open Enrollment
Nov. 1 – Dec. 15, 2019

Coverage starts: Jan. 1, 2020

What you can do: Enroll in health insurance coverage through the insurance marketplace or update your existing coverage.

Where to start: Healthcare.gov

Medicare Advantage Transition Period and Original Medicare Late Enrollment
Jan. 1 – March 31, 2020

What you can do:

  • Leave your Medicare Advantage plan and return to Original Medicare.
  • Switch to a different Advantage plan once during this period.
  • Enroll in Medicare Parts A and B if you missed your initial enrollment period. (A late-enrollment penalty may apply, coverage begins July 1, 2020).