Many Americans are facing changes to their health insurance this year. A sudden loss of income, moving to another state, or changing jobs can affect coverage.
“These and other changes in your personal circumstances may force you to choose a new plan, impact your eligibility for coverage, or increase how much you pay for it,” notes Melanie Steele, Director of Patient Financial Engagement at Memorial Sloan Kettering.
Whether you have health insurance through your employer, the Health Insurance Marketplace (a resource of the Affordable Care Act), or Medicare, you will have the opportunity to switch health plans during the open enrollment period. Depending on the plan, open enrollment generally runs from mid-October until mid-December.
Ms. Steele explains what you should know before making a selection.
Why might I need to change my plan?
You may need to adjust your health coverage needs as a result of certain changes in employment, income, and marital status, or upon the loss or addition of any dependent, such as the birth or adoption of a child. While such life events would qualify you to make changes to your plan at any time, open enrollment offers another window of opportunity if you haven’t already done so.
You may also want to reevaluate your plan if you’ve been diagnosed with a chronic disease or other serious illness. You’ll need to know which plan covers the specialists and prescription medications — as well as surgery and other treatments — that you may need.
If you become disabled or are 65 years old, you are eligible for Medicare. “There are different eligibility requirements and restrictions for traditional Medicare and Medicare Advantage plans,” notes Ms. Steele. “You will need to do a bit of research to understand which Medicare plan works best for you.” A good place to start is Medicare.gov, the official US government site where you can access information about Medicare enrollment, benefits, providers, and more.
What should I consider before I make any changes?
“It’s important to understand your current healthcare needs and to know what your options are,” advises Ms. Steele. Think about how often you and your family go to the doctor. If you historically haven’t needed healthcare services beyond wellness visits, you may not feel the need to pay for a more comprehensive plan. “It’s also key to consider your expenses and what you can afford,” adds Ms. Steele.
Find out what exactly is covered for you and your dependents. Ask if your preferred physicians, hospitals, and prescription services are in-network (part of the health plan’s network of providers with which it has negotiated a discount). Will you have to pay more for care at an out-of-network hospital? Are you willing to pay higher deductibles for the ability to branch out and see an out-of-network provider? For example, PPO plans are more expensive, but they offer more flexibility and allow you to access a hospital out of network.
If your insurance is through your employer, call your employer’s benefits office to discuss any concerns you may have about potential coverage. “If you are currently in treatment and you still have questions about your coverage, you can contact your hospital’s Patient Financial Services department and they can help you understand how changes to your insurance may impact your financial responsibilities,” says Ms. Steele.
What is COBRA and when is it an option?
COBRA is a health insurance program that allows for continued coverage when an eligible employee leaves their job. COBRA benefits allow you to keep employer-sponsored health insurance after it would have ended. However, COBRA is usually more expensive than the same plan used by active employees because the employer is no longer contributing to the cost of your plan.
If you are unable to pay for COBRA or it is about to expire — coverage usually lasts for 18 to 36 months — reach out to your hospital’s financial assistance program to discuss your options.
What is Medicaid and when is it an option?
If you become uninsured and cannot afford COBRA or private insurance, Medicaid may be an option. The Center for Medicaid and Children’s Health Insurance Program (CHIP) Services is a federal and state program that helps with medical costs for some people with limited income and resources. Check with your state’s Medicaid office to see if you or your family members are eligible for benefits.
Where can I get help if I have questions?
“Your hospital’s Patient Financial Services staff, including our office at MSK, can help answer your questions and offer guidance,” says Ms. Steele. “They can set up time to counsel you and your loved ones over the phone.”
If your coverage is due to terminate or change and you’ve already begun treatment that requires multiple visits, such as chemotherapy or radiation, speak with your insurance company and ask if they can offer continued coverage with your current provider while you seek out a new plan. Additionally, you should speak to someone at your hospital’s Patient Financial Services office so that they can help you through the process. “You may think that the hospital is automatically notified that your insurance has changed, but they actually don’t know this unless you tell them,” says Ms. Steele.
If you are experiencing financial hardship, ask whether you are eligible to receive financial assistance, which is based on your income and other assets. Co-pay assistance programs are also available to help cover out-of-pocket expenses for your prescription medication. These are provided through a mix of hospital, philanthropic, and pharmaceutical company-based programs. You may also call Patient Financial Services or the hospital’s Social Work department to discuss other financial resources that cover nonmedical needs like housing and transportation.
Employers may be able to help if you are having financial difficulty with an employer-based health plan. Speak with your benefits department and explain your situation to see if accommodations can be made.
If you’re an MSK patient, visit our Insurance & Assistance page to learn more about which insurance plans participate with MSK and about our financial assistance and co-pay assistance programs. You can also contact your doctor’s office and ask to speak with a Patient Financial Services patient access coordinator to discuss your coverage.