A note about this blog post: it’s a long one. We recommend grabbing a cup of your favorite pumpkin spice and reading it at your leisure or bookmark it for reference later.
Options for consumers under the Patient Protections & Affordable Care Act and beneficiaries in Medicare
In the early days of passing the Affordable Care Act (ACA) the cultural buzz was to get everyone thinking about their coverage options for the upcoming year, regardless of how one is insured. This cultural shift is happening now and, while the dates are not quite aligned, the last quarter of the year where people decide on their coverage options is now inclusive of Medicare beneficiaries, employees, and those needing coverage through the qualified health plans made possible through the ACA. While Medicaid and theChildren’s Health Insurance Program (CHIP) remains year-round, due to advertising, this is also a time when people with Medicaid and CHIP may also pay closer attention to the health care they can access.
This blog highlights a few key things critical to know for 2022, including links to some of our favorite resources and information by the Medicare Rights Center for Medicare beneficiaries and those who work with them.
Consumer updates enrolling in ACA coverage options
After a banner year of increased enrollments, we are now entering open enrollment season. For those who do not have employer-based health coverage, beginning this year, consumers who need health coverage made possible through the ACA will have an extra 30 days to review and choose health plans through Open Enrollment on the federal marketplace, which will run from November 1, 2021, throughJanuary 15, 2022, on HealthCare.gov. For individuals living in a state that has its own marketplace – such as California, New York, Washington, and others – they will have timeframes for open enrollment set by their state. Bookmark this tremendous blog for more details at healthinsurance.org.
Thanks to the American Rescue Plan, affordability is expanded to more people and improved even further because people with incomes under 150% FPL can enroll or change plans throughout the year via a new monthly special enrollment period (SEP). To learn more about the details see Kaiser Family Foundation’s overview. For the full list of SEPs available clickhere, including SEPs made available due to COVID-19 or natural climate disasters. Just a note that state-based marketplaces (e.g., in Washington, DC or Maine) can create more generous SEP opportunities, but they cannot reduce SEP opportunities made available through the federal marketplace.
To find help enrolling in an ACA-related plan the Get Covered Connector is available through Young Invincibles and their Navigator partners. This tool can point people in the right direction. Alternatively, you can find the list of Navigators in the federal marketplace here. To know whether or not your state participates in the federal marketplace or has its own start here with this map from the Kaiser Family Foundation. To fully understand how in-person and now telephone optional enrollment assistance works, you can gain insights and background through the Centers for Medicare and Medicaid Services (CMS) Center for Consumer Information and Insurance Oversight (CCIIO).
A quick note on health sharing ministries, short-Term, limited or “junk” plans—essentially any plans not sold on healthcare.gov or your state-based marketplace
They’re still around, and the ads and appeals are personalized to your algorithms. Consumers fall prey to them looking for a “deal” but none of these options have consumerprotections and do not comply with federal laws around affordable health coverage, nor are they insurance. Think of these as a risk pool, or rather, a betting pool, you are betting on winning access to health care by paying into it. These plans are not sold through healthcare.gov or state-based marketplaces. If you want to avoid the pitfall of extreme out-of-pocket costs in the tens of thousands, select a qualified health plan through healthcare.gov. Read more about “junk” plans and how to identify them via this still-relevantfact sheet from The Kaiser Family Foundation. Again, all Medicare beneficiaries or those new to Medicare should start with Medicare.gov
Medicare Fall Open Enrollment Reminders for Beneficiaries
During Medicare Fall Open Enrollment (October 15th – December 7th), people with Medicare can make unrestricted changes to their coverage options. They can make as many changes as they need, and the last change they make on or before December 7th will take effect on January 1, 2022. People with Medicare can:
Switch between Original Medicare with or without a Part D plan and Medicare Advantage
Before you enroll in a new plan, follow some simple advice to find the best plan for your situation.
Use Medicare’s Plan Finder tool to search for Medicare Advantage or Part D plans.You can use the Plan Finder tool to compare plans based on covered health care services, the drugs you need, the pharmacies you use, and prescription drug costs. You can also call 1-800-MEDICARE to find out which Medicare Advantage and Part D plans are available in your area. When you receive the list of plans, check the plans’ websites or call them to see which best fits your needs.
Call a plan directly to confirm any information you read online. Make sure the plan includes your doctors, hospitals, and other providers in its network. Confirm that the plan covers all your prescription drugs, and that your pharmacies are preferred and in-network. When speaking with a plan representative, write down everything about your conversation, including the date, the representative you spoke to, and any outcomes or next steps.
This information may help protect you in case a plan representative gives you misinformation.
A note about delaying enrollment into Medicare. This is a complex topic idiosyncratic to your situation. Delaying enrollment in certain Parts of Medicare (e.g. Part B) could result in hefty, lifelong late enrollment penalties. We strongly recommend researching this further based on your situation and note that employers to do not always understand the nuances of Medicare enrollment periods, especially when it comes to extending health insurance through COBRA. Learn more here.
For Medicare consumers and those assisting them, the Medicare Rights Center, a national nonprofit, is available to provide help with decision-making and determining next steps for open enrollment, and other enrollment periods.
If there’s one mantra for the open enrollment season, it’s “review your options.” Every year, the Medicare Rights Center advises people with Medicare to carefully consider how they get their Medicare benefits; most people are allowed to make changes only during Fall Open Enrollment. Here is some tried and true advice we offer beneficiaries depending on their Medicare coverage.
If you have Original Medicare and a supplemental plan (often called a Medigap) and are happy with your coverage, you do not need to make a change.
If you have a Medicare Advantage or Part D plan, you should review all your coverage options even if you are happy with your current coverage, because plans change their costs and benefits every year.
Read your Annual Notice of Change (ANOC), which you should receive from your plan by September 30. It will list the changes in your plan, such as the premium and copays, and will compare the benefits in 2022 with those in 2021.
Consider all your options, since many plans make changes every year, and your current plan may not be your best choice for 2022. Shop around to find a plan that best meets your needs and makes the most financial sense to you.
COVID-19 Updates Specific to Medicare for 2022
Medicare Coverage in Response to COVID-19. Medicare covers certain medically necessary services and items related to COVID-19, such as COVID-19 vaccines and testing, telehealth, and prescription refills. Original Medicare Part B covers COVID-19 vaccines, regardless of whether you have Original Medicare or a Medicare Advantage Plan. A beneficiary will not owe cost-sharing (deductibles, copayments, or coinsurance). COVID-19 testing is covered under Medicare Part B. A beneficiary pays nothing for the test if they have Original Medicare and see a participating provider, or if they have a Medicare Advantage Plan and see an in-network provider.
Telehealth. Medicare generally only covers telehealth in limited situations but has expanded coverage and access during the COVID-19 public health emergency. During this time, Medicare covers hospital and doctors’ office visits, behavioral health counseling, preventive health screenings, and other visits via telehealth in settings that include a beneficiary’s home. Standard cost-sharing may apply. If a beneficiary has a Medicare Advantage Plan, they should contact their plan to learn about its costs and coverage rules.
Telehealth services generally require both audio and video, but certain telehealth services can be delivered using only audio. These services include some behavioral health care and patient evaluation and management. If a beneficiary has questions about technology requirements for telehealth services, they should ask their provider.
Prescription drug refills.During the emergency, all Medicare Advantage and Part D plans must cover up to a 90-day supply of a drug when requested. Plans cannot use quantity limits on drugs that would prevent a beneficiary from getting a 90-day supply, if the beneficiary has a prescription for that amount. However, some safety limits are still in place to prevent unsafe doses of opioids.If a beneficiary takes medications that are covered by Medicare Part B, they should ask their doctor and plan for more information about ensuring they have an adequate supply.
Now on to our updates for the outreach and enrollment workforce for ACA and Medicare coverage
In order to serve diverse communities with expansive needs, it is important to emphasize that enrollment assistance must be made available in the person’s preferred language, and it must be culturally and linguistically appropriate. This is why Navigators and Certified Application Counselors are an essential workforce because they are the trusted messengers of their communities. For post-enrollment follow up resources in other languages, CMS has posted a variety of digital resources available to print.
Conversely, for help with Medicare, there is a local State Health Insurance Assistance Program (SHIP) volunteer counselor in every state. To find personalized assistance in your state, locate your SHIP counselor here.
The essential outreach and enrollment workforce assisting with ACA coverage enrollment
In addition to all of the better news this year, CMS finalized a rule that would increase the user fees for the marketplace which pays for increased advertising and the Navigator workforce. This is a welcome shift for consumers who will have increased access to this workforce that for the past four years was cut across the board to a near simmer.
For some tried and true time-tested, reliable neutral resources to support ACA-related enrollment we are highlighting two key list serves to sign up for and bookmark.
For new Navigators and Certified Application Counselors (CAC), and others just starting to understand the work of year-round enrollment assistance through the federal marketplace we recommend getting on the following list serves, Georgetown’s Center on Health Insurance Reforms(CHIR) and the Center on Budget and Policy Priorities Beyond the Basics training series. Both are chock full of details related to application assistance and appeal rights. It is key to know for employers of Navigators and CACs that enrollment assistance is expected to be provided year-round, sometimes referred to as post-enrollment follow-up about filing appeals, updating income, understanding how to use coverage, and more.
Notably, Transform Health continues to assist outreach and enrollment focused staff on their strategies and plans. For training ideas about creating virtual enrollment opportunities, see our virtual enrollment workflow created and supported by the National Association of Community Health Centers (NACHC). For newly released evergreen job description templates that Transform Health created with the support of NACHC and CACs across the country click here. These job descriptions can be expanded upon or adapted for any outreach and enrollment workforce.
For more information on how workforce impacts health coverage, check out the latest Census data. You can choose different variables down to a zip code level to help prioritize areas to conduct your outreach efforts. The data from the census is still new and therefore paints an overall picture of health coverage in your state, county, or city at this point in time.
And when it comes to Medicare if you are wondering how to best start when it comes to Medicare decision-making, visit the Medicare Rights Center’s consumer-friendly Medicare Interactive to learn about all of the differences between Original Medicare and Medicare Advantage, and subscribe to the Medicare Rights Center’s free newsletters for regular updates on the latest Medicare information.
If you would like to learn more or work with Transform Health please contact Heather Bates at email@example.com