Don’t Miss Your Window: Tips and Considerations for Medicare and Marketplace Open Enrollment

Information from Don’t Miss Your Window: Essential Tips for Medicare and Marketplace Open Enrollment webinar presented by Emily Brown, BSW

This information covers the basics of open enrollment, the health insurance marketplace, Medicare, and special considerations for those diagnosed with MSA.

Background on Patient Advocate Foundation

Patient Advocate Foundation began in 1996 with a volunteer staff of two, serving 150 patients in its first year. Over 25 years later, we have a full-time staff of over 220 and have directly assisted over 2 million patients. Our services are free and provide support to patients of all backgrounds, ages, employment statuses, and incomes. We offer case management, financial aid for co-payments and premiums, and educational initiatives for patients and caregivers.

Overview of Open Enrollment

Open enrollment is the time each year when you can shop for insurance, buy insurance for the first time, continue with your current plan, or purchase a new one. Enrollment periods vary in length, usually from two weeks to a few months. Changes made during open enrollment take effect the following year.

For example, the health insurance marketplace opens November 1st and closes on January 15th. If you sign up by December 15th, coverage begins January 1st; if you sign up by January 15th, coverage starts February 1st. Employers, Medicare, and other plans may have different open enrollment dates, so be sure to check specific deadlines.

When choosing a plan, it’s essential to consider not only the monthly premium but also other costs such as deductibles, copays, and out-of-pocket maximums. These choices will also affect which providers and medications are covered by your plan.

Ways to Obtain Health Insurance Coverage

You can obtain coverage through several channels:

1. State Marketplace/Exchange: Each state has its own health insurance marketplace with links available at healthcare.gov.
2. Employer-Based Coverage: Many employers offer insurance and often cover a portion of the premium.
3. Parental Plans: If you’re under 26, you may be covered under your parents’ plan.
4. Medicare: Available for those over 65, with certain disabilities, or specific health conditions. More details can be found at medicare.gov.
5. Medicaid: A state-run program for low-income individuals, families, children, and disabled persons. Additional information is available at medicaid.gov.
6. Private Insurance: You may also purchase coverage directly from insurance companies, agents, or brokers, though these plans may not be eligible for marketplace subsidies.

Health Insurance Marketplaces

The marketplace simplifies plan comparison by categorizing options into bronze, silver, gold, and platinum levels. Bronze plans cover about 60% of costs, while platinum plans cover around 90%. Premiums and out-of-pocket costs vary by level.

Medicare Overview

Medicare, managed by CMS, serves those 65+, younger people with disabilities, individuals with end-stage renal disease, and those with ALS. Medicare has multiple parts:

• Part A: Covers hospital stays, skilled nursing, and hospice care.
• Part B: Covers outpatient care, lab tests, and medical equipment.
• Part D: Covers prescription drugs. Medicare Advantage plans, or Part C, combine A, B, and sometimes D, providing additional benefits through private insurers.

Enrollment Periods for Medicare

Medicare has several enrollment periods:

1. Initial Enrollment: A seven-month window around your 65th birthday.
2. Annual Open Enrollment: October 15th to December 7th, allowing plan changes for the following year.
3. Medicare Advantage Open Enrollment: January 1st to March 31st, allowing changes within Medicare Advantage plans.

For individuals over 65 who still work and have employer coverage, check with HR to determine whether you need to sign up for Medicare immediately or can delay without penalty.

Financial Assistance and Premium Tax Credits

Financial assistance is available through the marketplace in the form of premium tax credits and cost-sharing assistance. Eligibility depends on income and family size. Financial assistance reduces premium costs and is applied in advance but be sure to update your income if it changes to avoid repayment.

Comparing Plans and Coverage

When choosing a plan, compare premiums, deductibles, and out-of-pocket maximums. Check if your preferred providers, pharmacies, and medications are covered. Consulting with your care team can help ensure that your chosen plan will cover your medical needs effectively.