Patient advocate assists elderly woman with cane

Have you been working with patients to re-evaluate their commercial health plan or Medicare plan?  As a patient advocate, now is the time. 

Open enrollment for 2021 is underway and ends in a few short weeks! For Medicare patients and all patient advocates helping during this time, the enrollment deadline is December 7th! For commercial plans through the marketplace at, the deadline is December 15th.

If you don’t act by those dates, you will not get 2021 coverage unless you qualify for special enrollment.

A patient qualifies for the Special Enrollment Period when they lose health insurance through qualifying life events. These include losing health coverage, moving, marriage, divorce, adopting a child, or having a child. Most people do not qualify for a Special Enrollment Period, so the time to enroll is now. 

Things to consider with Medicare Plans (or any health plan):

☑️ monthly premium  

  • A  monthly premium is a monthly enrollment cost to maintain coverage as an active member of the health plan. This is the cost that a patient has monthly, regardless of health status or health needs.

☑️ out of pocket costs  

  • The out of pocket costs are the costs the patient is responsible for when they seek out health care. This includes if the patient gets sick or needs to see a doctor frequently. These fees can be different for primary care physicians, specialist doctor visits, emergency department visits, etc. 
  • Also keep in mind any co-insurance that may be applicable. Co-insurance is cost sharing the patient has with the insurance company. The patient may be responsible for a portion of the total cost of treatment. 

☑️ traveling habits  

  • For some patients, their travel habits may play a large part in their health insurance choice. It is particularly relevant when they need healthcare out of state. For those who travel frequently or have multiple residencies, they may require a broad inclusive network for healthcare providers. 

☑️ current drug therapy

  • Evaluating a plan’s formulary before signing on to an insurance plan is important because it will help you budget your monthly costs. It is important for patients and advocates to check the formulary for their current drug therapies.
  • If a drug is not available on formulary or is not on a preferred tier, this could result in patients higher monthly costs for therapy, needing prior authorization, or a change in therapy. 

Understanding monthly costs, overall costs, and benefits before signing up will make the following year a bit less stressful.

Keep in mind – All changed plans take an effect January 1st!

The National Board of Prior Authorization Specialists (NBPAS) is an ACMA company focused on establishing benchmarks of excellence for the life science and healthcare industries. We specialize in improving prior authorization performance. For example, reducing denials and increasing revenue retention associated with reimbursement claims. Set yourself apart with prior authorization and reimbursement knowledge with the Prior Authorization Certified Specialist program (PACS).