Two Scary Words: Open Enrollment

Labor Day is a key milestone for a lot of people. Kids are starting back to school. Retailers put swimwear on sale and start making space for holiday merchandise. And both insurance companies and those they insure brace for open enrollment.

Open enrollment is that period where you evaluate insurance plans for the following year. Whether you’re covered through your employer, through Medicare, or through other insurance plans, it’s critical that you arrange for coverage because missing these deadlines can make it difficult to obtain coverage once open enrollment ends.

The really scary part is that until the new plans are announced, there is no way to know what coverage will be available and, importantly, what it will cost. However, it’s practically impossible to avoid the headlines about rising health care costs and, especially rising prescription costs. In addition, some insurers have exited the healthcare marketplace and/or stopped issuing certain individual policies altogether. This has left hundreds of thousands of people scrambling for coverage. Notably, this year Blue Cross Blue Shield of Texas stopped issuing individual PPO plans affecting nearly 400,000 people in Texas alone.

In an effort to control costs, many insurance companies are targeting drugs to treat inflammatory conditions such as rheumatoid arthritis. Recently Express Scripts, which is a major benefit provider, has set up special programs specifically to manage these costs and this includes limiting the drugs they will actually cover. Other insurers are employing different tactics, such as only filling half a prescription for expensive drugs for conditions such as cancer. I expect to see more of these types of limitations in this year’s offered insurance plans.

It’s no secret that biologic drugs used for RA and other inflammatory or autoimmune diseases are costly. Express Scripts stated that while less than 1 percent of their members use these drugs, they account for more than 10 percent of the prescription drug costs. In Texas, both Enbrel and Humira, two of the most popular drugs to treat RA, made the Top 10 Costliest Medicare Part D drugs.

I understand that insurance companies are truly caught in a crunch between trying to provide reasonable benefit plans and control the ever-escalating costs of health care. However, those of us with chronic conditions are dependent upon these drugs to help manage our disease and to help provide some quality of life. For many, these drugs are what stand between a full, productive life and one constrained by disability. While achieving remission is a priceless goal, it could very well be one that many people simply cannot afford.

For its perceived shortcomings, I was very thankful for the healthcare reforms that went into place a few years ago. Without them, someone with RA or other pre-existing condition might not be able to get health care at all. However, adjusting to these new guidelines is also a major cause of insurance companies limiting their coverage options and raising their premiums. More people with costly, chronic conditions are able to obtain coverage while many younger, healthy people are not signing up for coverage because of the prohibitive cost.

Regardless of where you are in this equation, it will soon be time to evaluate your options and make some critical decisions about next year’s insurance coverage.

Open enrollment for Medicare starts October 15 and the government’s healthcare marketplace and (generally) other private insurance on November 1. If you get insurance through your employer, the enrollment period will vary but will also be during this same general timeframe. You must enroll by a specific deadline to make sure your coverage starts January 1, 2017. This is December 1 for Medicare coverage and December 15 for marketplace plans.