The fall is a busy time for people who need to sign up for healthcare coverage through Medicare or the Affordable Care Act (ACA). The Medicare Open Enrollment period occurs each autumn from October 15 through December 7. Meanwhile, open enrollment for the plans certified by the ACA’s Health Insurance Marketplace begins on November 1. The last day to enroll or change plans for coverage to start on January 1 occurs on December 15, and open enrollment ends on January 15. 

This year, there are a few key things to keep in mind as the enrollment period looms. Some of them are the result of the legislation known as the Inflation Reduction Act (IRA) of 2022, and the good news is that patients may be able to anticipate some cost savings in 2024. 

This information can guide you as you work with patients to better understand their coverage in 2024. 

Changes with Medicare Part D

Medicare recipients can expect their average monthly premiums for prescription drug coverage to drop slightly in 2024. The Centers for Medicare & Medicaid Services (CMS) has forecasted a decrease in Medicare Part D premiums in 2024. This is the result of the IRA, which made improvements to Part D coverage. Also thanks to the IRA, Part D premiums cannot increase by more than 6% starting next year.

Come January, plans will no longer be able to apply the Part D deductible to any insulin product listed on its formulary–or charge more than $35 for a month’s supply of insulin in the initial or gap coverage phase. In addition, eligibility for the Part D Low-Income Subsidy (or “Extra Help”) Program will be expanded.

Changes with Medicare Advantage

Starting in 2024, a patient with medication coverage through their Medicare Advantage plan (or Part D) won’t have to pay anything for the cost of their prescription drugs for the rest of the year if they reach what’s called “catastrophic coverage.” The threshold for entering catastrophic coverage in 2024 is $8,000. This may save some beneficiaries, notably those who spend a significant amount of money each month on prescription drugs, thousands of dollars. 

Changes for ACA Plans 

Coverage under the ACA may be more accessible in the new year. Earlier this year, the IRS announced a drop in the 2024 health plan affordability threshold. The threshold will be 8.39% of an employee’s household income, down from 9.12% in 2023. In fact, the drop will make it the lowest affordability threshold since the Affordable Care Act was implemented, according to SHRM (Society for Human Resource Management).

Tips for Insurance Optimization

Choosing the right plan—or switching to a different plan—can be overwhelming for patients. 

For example,  more and more people eligible for Medicare are now choosing to enroll in a Medicare Advantage plan, a private plan alternative to traditional Medicare. In fact, in 2022, nearly half of the Medicare population went this route, according to the Kaiser Family Foundation (KFF).

But now they have to choose between a growing number of plans, and that can be challenging to navigate. Last year, Medicare beneficiaries could choose between 43 different Medicare Advantage plans offered by private companies for 2023 coverage.

That’s when navigators, advocates, and other professionals can step in. Specifically, they can help make sure their beneficiaries are enrolled in the most cost-effective plans. Here are some other tips that can help you help your patients:

1. Talk to patients about their existing coverage

Start by talking to your patients about their existing coverage.  As you help them review their current plan to find out what’s covered, use this checklist of questions:

  • Are your doctors in network for your current plan?
  • Is your preferred pharmacy in network?
  • Is your preferred health system in network?
  • Does your plan’s formulary include all the prescription medications that you need to take?

2. Check in with patients turning 65

Make a special point to check in with patients who are turning 65 and becoming eligible for Medicare. They may not fully understand how Medicare enrollment works. You can explain the differences between the Initial Enrollment Period, which begins when they turn 65 and lasts seven months, and the General Enrollment Period. How to find them: technology can help flag patients who are turning 65 and can now sign up for Medicare. 

3. Consider other plan options

If your patient isn’t satisfied with their current plan, or they realize that their doctors, hospitals, or medications aren’t covered by their existing plan, you can encourage them to consider switching to a different plan during Open Enrollment. 

Before they switch, you can encourage patients to assess their options and review the ratings for various plans. For example, they can visit  Healthcare.gov to review ACA plans and prices, or they can review Medicare plans and prices on the Medicare.gov website. 

4. Educate patients on plan types 

Patients may not understand the differences between plan types. 

For example, there are four types of plans that are certified by the ACA Health Insurance Marketplace: HMOs, PPOs, POSs, and EPOs. You can explain the major distinguishing factors about each plan and help them determine what might be most appropriate for them. They might be interested in switching from one type of plan to another, and the only time to do that is during Open Enrollment. 

Meanwhile, Medicare beneficiaries can choose to stay in traditional Medicare or go with a Medicare Advantage plan. Financial navigators can explain that there are pros and cons to both. For example, some experts suggest that an upside to choosing Medicare Advantage is that it can be more affordable. But a patient must balance that benefit with downsides, such as geographical restrictions and closed provider networks, which are limitations on the providers that patients can access. They can also choose to switch Medicare Advantage plans. 

5. Tutor patients on enrolling

You can’t actually enroll a patient in a health plan, but you can educate them and help walk them through the process. 

6. Consider pre-enrollment education for yourself

There’s a lot to know, so if you or anyone else on your team needs to brush up on key points, it may be worth checking out educational opportunities. For example, CMS offers Navigator and Certified Application Counselor Training Courses. 

The Future of Affordable Care

Stay tuned, because other changes are coming down the pike, including provisions from the IRA that will take effect in future years. 

For example, beginning in 2025, out-of-pocket prescription drug spending for Part D beneficiaries will be capped at $2,000. Part D enrollees will also be able to opt to pay their out-of-pocket costs in monthly installments, rather than at the point of sale. Another provision of the IRA directs CMS to negotiate drug prices covered under Part D. Those reductions should take effect, depending on the outcomes of legal challenges, in 2026. 

By following the tips above and staying abreast of relevant policy changes, navigators and other professionals can play a key role in ensuring patients understand their coverage and choose the best possible plans.