Open enrollment for healthcare coverage runs from October 15 through December 7 for Medicare and from November 1 through January 15 for ACA Marketplace plans. As the patient affordability crisis looms large and the costs of care continue to rise, ensuring patients have good healthcare coverage is essential.  

Between the alphabet soup of acronyms and a seemingly interminable menu of plan options, navigating the complex health insurance landscape can be downright confusing. Many Americans find it difficult to understand their options and find a plan that fits both their budget and healthcare needs. A study of nearly 24,000 employees at a Fortune 100 company found that 61% had chosen an inadequate health plan. 

Choosing the wrong coverage can have detrimental effects. In 2022, nearly 44% of Americans delayed or skipped seeking healthcare services due to cost. It doesn’t have to be this way. Financial navigators play a key role in helping patients find and enroll in a plan that meets their medical and financial needs. 

Open enrollment is the perfect time for financial navigators to help patients optimize their coverage and lower their out-of-pocket (OOP) expenses to ensure they can get the care they need, when they need it.

Read on for tips to make the most of open enrollment and improve patient affordability:

1. Educate Patients to Improve Health Literacy

The Inflation Reduction Act extended the American Rescue Plan Act (ARPA) premium subsidies, which increased insurance tax credits to people with incomes 400% below the federal poverty level (FPL) and extended eligibility of credits for people with higher incomes. Extension of these subsidies will help 3.3 million people keep their coverage. To take advantage of these programs, patients must first be aware of them. But the complexity of healthcare in the U.S. leaves many Americans confused about their options. 

An estimated 80 million American adults have limited or low health literacy, and many report confusion about basic health insurance terms, such as coinsurance, copayment, and deductible. Medicare beneficiaries have additional complexities to contend with and must understand the four parts to Medicare (A, B, C, and D) to optimize coverage. 

Studies show that individuals with low health literacy are less likely to utilize preventative healthcare services and have poorer health outcomes. Financial navigators are in a unique position to educate patients on key terminology, so that patients can more confidently choose the right plan. Adequate health literacy improves treatment adherence and leads to fewer hospitalizations and greater cost savings to the healthcare system. 

2. Optimize Patient Health Insurance Coverage 

While many Americans may assume that their health insurance plan will help cover their costs when they get sick or injured, not all plans provide the coverage patients need. In 2022, 43% of working-age adults were inadequately insured, 23% had insurance that did not provide them with affordable access to healthcare, and 11% had a gap in coverage.

The high costs of monthly premiums are the primary reason more than four in 10 people report dropping their coverage or opting out of Marketplace plans. 

Financial navigators can help ensure patients are adequately insured without the risk of financial stress by evaluating their existing coverage and out-of-pocket maximum and finding ways to optimize that coverage:

Marketplace Coverage

  • For patients who obtain insurance through the Marketplace, financial navigators can help patients review their current plan and their options. It can be helpful to explain the different tiers — bronze, silver, gold, and platinum — and each tier’s associated premiums, deductibles, and share of costs covered.
  • It’s also important for patients to understand the different types of plans, including health maintenance organizations (HMO), preferred provider organizations (PPOs), exclusive provider organizations (EPOs), and point-of-service plans (POS), so they can ensure their preferred providers, pharmacies, and hospitals are in-network with their plan. 

Medicare Coverage

  • When it comes to Medicare, many beneficiaries find comparing and understanding plans frustrating and challenging. In 2020, 71% of Medicare beneficiaries did not compare plans during open enrollment. Given the complexities of the Medicare system, the Department of Health and Human Services is distributing $98.9 million in grant funding — the largest navigator funding to date — to financial navigation organizations for the 2023 open enrollment period.
  • Financial navigators can help reduce barriers to understanding by breaking down the various Medicare parts — Parts A, B, C, and D — and explaining what each part covers. Look for any upcoming changes to a patient’s existing plan and compare plan options to ensure they get the most out of their coverage.
  • Explaining the benefits of Medicare Part D (prescription drug benefit) is particularly valuable. Certain provisions of the Inflation Reduction Act aim to help Medicare beneficiaries to save costs on medications. Among other changes, the new legislation will add a $2,000 out-of-pocket cap on Medicare Part D beginning in 2025, which could mean significant savings for those with high-cost conditions.
  • It’s also important to make patients aware of Medicare Advantage, supplemental plans (Medigap), and the Medicare Savings Program (Extra Help)

With both ACA plans and Medicare (and even employer plans) it is important to look at the choices side by side and view the total cost of the premiums as well as the out-of-pocket maximum.  This can guide decisions by seeing the overall potential cost of a plan.  

If you need assistance evaluating the best options for patients, help is available 24 hours a day, seven days a week through the Marketplace or Medicare hotlines, or via live chat on the Medicare website.

3. Make Patients Aware of Financial Assistance 

Though the ACA and Medicare set important consumer protections, many patients continue to face high out-of-pocket costs and have difficulty accessing treatment. 

In addition to working with patients to optimize their healthcare coverage, financial navigators can let patients know that they are there to help beyond the enrollment process. Financial support is available to qualifying patients through drug manufacturer copay assistance programs, disease-specific charitable funds, and other resources. These programs are designed to help patients access the healthcare and treatments they need.  

Charitable funds often close quickly and many tend to dry up by the end of each calendar year; patients may be placed on a wait list or need to wait to apply until the funds reopen. The good news is that many charitable foundations reopen patient assistance programs in January, thanks to a boost in philanthropic donations at the end of the year. 

Drug manufacturer assistance programs may cover patient out-of-pocket costs for high-cost treatments or offer free medication to those who are uninsured. Community-based resources and disease-specific funds may help cover the costs of care and/or daily living expenses, such as food, transportation, and rent.  

The Impact of Improving Patient Affordability

By evaluating and facilitating enrollment in ACA and Medicare plans, financial navigators can help ease the financial burden of care for patients and the entire healthcare system, leading to: 

  • Reduced risk financial toxicity 
  • Higher rates of adherence 
  • Improved patient health outcomes
  • Lower rates of bad debt and uncompensated care

Fortunately, digital solutions can help automate the manual, time-consuming process of matching the right patient with the right plan. For example, through its Insurance Optimization capabilities, TailorMed can perform a dynamic analysis of a patient’s coverage, identifying opportunities to maximize benefits and enroll in additional coverage – or a more cost-effective plan. Most importantly, these types of tools allow navigators to spend less time on cumbersome tasks – and more time serving patients.

As the costs of healthcare continue to soar, financial navigation services for patients are more important than ever. This open enrollment season is the perfect time to assess patients’ financial health, optimize their insurance, boost their health literacy, and make them aware of financial assistance programs to ensure they have the best possible coverage and care.

For more helpful tips, read our open enrollment overview and watch our best practices webinar.