Insurance Open Enrollment

When you can change plans

Medicare: The annual open enrollment period runs October 15 – December 7 each year. During this window, Medicare patients can switch between Original Medicare and Medicare Advantage, change Medicare Advantage plans, or change their Part D prescription drug plan. Changes take effect on January 1.

Health insurance marketplace (ACA): Open enrollment typically runs November 1 – January 15. Outside that window, marketplace plans can usually only be changed after a qualifying life event, such as losing other coverage or a change in household.

Employer plans: If your insurance comes through a job — yours or your spouse's — the enrollment window is set by the employer and varies from company to company. Check with your employer or HR department for your exact dates.

How switching plans can affect your infusion care

Many rheumatology treatments — especially biologic medicines given by IV infusion or injection — are among the most closely managed benefits in any health plan. A new plan does not simply pick up where the old one left off. Four things commonly change:

New prior authorization. Approval from your old plan does not transfer. Your new plan will usually require a fresh prior authorization before it pays for your infusion medication, and that process takes time — starting it early is how you avoid a gap in treatment.

Formulary changes. Every plan keeps its own formulary — the list of medicines it covers, and on what terms. The biologic or infusion medication you take now may be covered differently under a new plan, require trying another medicine first, or not be on the list at all.

Where your infusion is covered. Plans differ on where infusion therapy may be given. A new plan might cover your infusions in our office, or might require a different setting, such as a hospital outpatient department. Before switching, confirm the plan covers infusion care at our office.

Out-of-pocket costs. Deductibles, co-insurance, and copays differ by plan and usually restart each January. The same infusion can cost noticeably more — or less — under a new plan, so it pays to compare your expected total costs, not just the monthly premium.

Before you switch: verify that the new plan covers your infusion medications and your care at our office — and tell our office before you switch, so we can re-obtain your authorizations under the new plan and keep your treatment on schedule. Bring your new insurance card to your first visit of the year, or send us a copy as soon as it arrives.

What is secondary insurance?

Some patients are covered by two health plans at the same time. The second one is called secondary insurance: it pays after your main (primary) plan has paid its share. Common examples include:

• A plan through your spouse's employer, in addition to your own coverage
• A Medicare supplement (Medigap) policy, which sits behind Medicare and helps with Medicare's cost-sharing
• Medicaid alongside Medicare — Medicare pays first and Medicaid may help with remaining costs
• A retiree plan from a former employer, layered on top of Medicare

How coordination of benefits works: when you have two plans, they coordinate through a standard process. The primary plan pays first, just as it normally would. Then the claim goes to the secondary plan, which may pay some or all of the remaining eligible costs — such as deductibles, co-insurance, and copays — according to its rules. Which plan is primary is set by standard coordination rules, not by choice.

How it can help: infusion medications and ongoing rheumatology care can leave patients with meaningful out-of-pocket costs even after the primary plan pays. A secondary plan can absorb much of that remainder, lowering what you owe for infusions, office visits, and other care. It adds paperwork behind the scenes, but for patients on high-cost therapies it can make a real difference.

One request: please tell our office about every insurance plan you have — primary, secondary, supplement, or prescription coverage — and let us know whenever one changes. Our billing team can only coordinate your benefits correctly if we have all of your plans on file; a plan we don't know about can delay claims and authorizations.

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