The new year is often a time of joy and hopefulness. For far too many patients, it is also a time of exorbitant healthcare costs.

One major reason is that in January, many health insurance plans renew. This includes many commercial plans—whether employer- or Affordable Care Act (ACA)-sponsored. It also includes plans offered by government programs such as Medicare, TRICARE, and Medicaid. 

When a patient enrolls in a new health plan or their plan renews at the start of the year, their out-of-pocket (OOP) maximum and deductible restart at zero. This means they pay a higher portion of their healthcare expenses than they would later in the year. And with the rise of high-deductible plans, these costs can quickly become unmanageable. 

During this season of peak financial responsibility for patients, financial navigators often face a sharp rise in their workloads. Navigators are busy enrolling new patients in health plans and financial assistance, as well as renewing and enrolling existing patients whose treatment carried over into the new year.

With greater needs and demands on their time, it can be challenging for navigators and other staff to determine which cost-saving opportunities to prioritize—and for whom. 

Here are the top priorities when assisting commercially insured, government-insured, and uninsured patients:

Who: Patients with Commercial Insurance

Top Priorities:

1. Insurance Optimization

  • The first step in working with patients, no matter what type of insurance they have, is to evaluate their existing coverage and OOP maximum. For those enrolling in or renewing a plan via the ACA Marketplace, the deadline for coverage beginning January 1 was December 15, 2023. However, even if patients missed this deadline, it’s not too late. Those who sign up by January 15 and pay their premium will receive coverage beginning February 1. And if they’ve had a qualifying life event—such as a loss of health coverage, a change in household income, or a move—they may be eligible for special enrollment outside of these dates. Enrollment dates may also vary by state.
  • This year, it’s especially wise to explore ACA options with qualifying patients. Thanks to the passage of the Inflation Reduction Act, patients may find more aid and lower premiums than in years past. 

2. Manufacturer Copay Assistance

  • Whether the patient has employer-sponsored insurance or an ACA plan, they may be eligible for manufacturer copay assistance. These programs help offset costs associated with copays, as well as deductibles and coinsurance. For patients with high-cost chronic conditions, these resources can make a tremendous difference.
  • Navigators should look at the patient’s treatment plan and then determine whether copay assistance is available for their medications. Program availability, eligibility requirements, and enrollment processes vary based on the pharmaceutical company’s guidelines. The good news is that these resources are available throughout the year.

Who: Patients with Government Insurance

Top Priorities: 

1. Insurance Optimization

  • Navigators should ensure that patients with government insurance are enrolled in the most cost-effective plans. For patients 65 and older, Medicare open enrollment ended on December 7, 2023. However, as with commercially insured patients, Medicare beneficiaries may be eligible for special enrollment. If patients qualify, it’s valuable to review their current coverage and compare options.
  • Navigators should also make patients aware of programs such as Medicare Advantage, supplemental plans (Medigap), and the Medicare Savings Program, also known as Extra Help. Notably, Extra Help offers special enrollment once per quarter for the first three quarters of the year. In 2024, Extra Help has increased its income eligibility to 150% of the federal poverty level (FPL). In the past, some patients only qualified for partial Extra Help, but now, all qualifying patients receive full program benefits.
  • This year, it’s especially crucial to communicate with Medicaid patients, some of whom may be facing loss of coverage due to the redetermination process. Navigators should ensure they understand their state’s rules regarding appeals and re-enrollment. For example, how long can the patient appeal? If the patient is re-enrolled, will they receive retroactive coverage? Patient education is key.
  • Military personnel, veterans, and their families may qualify for TRICARE benefits. TRICARE open enrollment for 2024 ended on December 12, 2023, but like Medicare, the program offers special enrollment.

2. Foundation Copay Assistance

  • Numerous charitable organizations such as the HealthWell Foundation, PAN Foundation, and the Patient Advocate Foundation offer copay assistance. However, unlike drug manufacturers, these organizations also offer funds to patients with government-sponsored insurance. Thus, navigators should explore available grants for patients who have Medicare, TRICARE, or Medicaid. Grants are typically disease-specific, based on the patient’s condition.
  • Many of these funds reopen in January. In fact, of the 400-plus foundation programs accessible through TailorMed’s platform, we found that 90 (22%) reopened in January. Now is the time to explore these options for qualifying patients. Many funds have a look-back period, so once the patient is enrolled, some claims may be covered retroactively.
  • NOTE: Programs often close quickly—sometimes within a matter of days or even hours—so it’s important to enroll patients as soon as possible.

Who: Uninsured Patients

Top Priorities:

1. Insurance Enrollment

  • Start by asking an uninsured patient why they don’t have coverage. For example, a patient may respond that they lost their job and their employer-sponsored insurance. This gives navigators the opportunity to discuss Consolidated Omnibus Budget Reconciliation Act (COBRA) benefits—or special enrollment in an ACA plan.
  • Low-income patients may qualify for Medicaid based on their household income, age, disability, and other factors. Eligibility criteria varies by state; an online screening tool is available via Medicaid enrollment continues year-round.
  • As noted above, some patients may have lost their coverage as a result of Medicaid redeterminations. If this is the case, it’s important to check whether they lost coverage in error and if they can appeal and re-enroll.
  • Whether the best option is Medicaid, COBRA, an ACA plan, or another type of insurance, it’s crucial to educate patients and help them enroll in affordable coverage.

2. Free Drug Programs and Charity Care

  • Drug manufacturers may provide free or low-cost medications to patients without insurance. Free drug orders are typically handled by a provider’s specialty or infusion pharmacy team; navigators should coordinate with pharmacy colleagues to review treatment plans and enroll eligible patients.
  • This year, due to the dynamic nature of drugmakers’ assistance programs, some patients who were previously eligible for free drug programs may no longer qualify. If this happens, it’s even more urgent for navigators to help the patient enroll in an affordable insurance plan, so that they might be eligible for foundation assistance. Foundations typically have higher income eligibility but they only assist insured patients.
  • Hospitals and health systems may also have their own internal charitable funds. Federal law requires that nonprofit hospitals provide some level of charity care—and many for-profit hospitals also offer these resources. While policies vary by organization, these funds are generally intended for low-income and uninsured patients.

Leaning into Financial Navigation Technology

Understanding financial assistance priorities is essential. However, even with this knowledge, the process of matching and enrolling patients is typically manual and time-consuming. 

Fortunately, technology solutions have emerged to automate the process and ensure patients secure the resources they need. For example, TailorMed’s platform supports the work of financial navigators and other staff by:

  • Identifying patients in need: Using data and predictive analytics, the platform flags financially at-risk patients—so that navigators can proactively help them before they face an unaffordable medical bill.
  • Maximizing benefits: The technology analyzes patients’ health coverage and provides options to optimize insurance, enroll in additional coverage, or switch plans.
  • Finding comprehensive funding opportunities: With thousands of financial assistance programs in existence, it’s difficult to find every available resource for every patient. Drawing from 6,000-plus copay assistance programs, grants, and other resources, TailorMed automatically finds the most relevant opportunities and the swiftest way to enroll the patient.
  • Addressing social determinants of health (SDOH): Technology can also help navigators identify funds to help offset nonmedical costs such as housing, transportation, food, and more. With patients feeling the pain of inflation, these resources can provide much-needed relief and peace of mind.
  • Notifying staff at the right time: The platform’s alerts let navigators know when relevant charitable funds reopen, so they don’t miss narrow application windows.
  • Centralizing navigation: Rather than relying on spreadsheets and Post-Its, navigators can manage their tasks, notes, patient approvals, internal communications, and other elements of their workflow in one location. The result is a more efficient experience, benefiting all parties involved.
  • Reaching more patients: With multiple responsibilities and limited time, navigators often aren’t able to help every patients in need. By automating workflows and enhancing productivity, technology empowers navigators to do more with the time and resources they have.

Removing Financial Barriers in January—and All Year

January is a time of heightened need for financial assistance, which can mean daunting workloads for financial navigators and other staff. By prioritizing insurance optimization and enrollment, then matching the right patients with the right resources with the help of technology, navigators can make the most of the season. Let’s start 2024 on the right foot—by helping patients afford care today and throughout the year.