ask the af open enrollment healthcare

#AsktheAF: Open Enrollment Edition!

During this season of open enrollment, the Arthritis Foundation is here to help you make an informed decision in selecting the best health coverage for your unique needs. Open enrollment is the time of year when individuals elect health care benefits through their employer, Medicare, Medicaid, or the federal and state health exchanges created through the Affordable Care Act. Open enrollment periods vary based on the type of insurance you have, but generally occur in the late fall.

As part of our commitment, the Arthritis Foundation hosted a webinar last month to provide a general overview of open enrollment and the tools and resources you need to secure the best health care for you and your family. In addition, we hosted our very first Twitter chat on November 9th devoted to this year’s open enrollment. Thousands of you engaged with us on Twitter to #AsktheAF and we rounded up your questions in one location.

Read on to learn more about open enrollment and the questions you asked during the Twitter chat. If you have further questions, the Arthritis Foundation also has licensed clinical social workers available to talk with you about these options or any other questions you may have about your care. Call toll-free at 1-844-571-HELP.

Federal Exchanges

What is the time frame for enrolling in a federal exchange plan?

Federal exchange enrollment is currently open and runs from November 1 to December 15. Visit to learn about your options.

What types of questions should I ask when considering my health plan options?

Several questions that you should consider asking when selecting a health plan include:

  • Can I use co-payment cards as a part of my insurance? Will my co-payment card apply to the deductible?
  • Is my specialty care doctor on the list of network providers?
  • Are my prescriptions covered under the major medical or pharmacy benefit?
  • What formulary tier do my prescriptions fall under?
  • Do I have a choice of more than one pharmacy provider?
  • What services require prior authorization?

Are plans based on age?

Under the Affordable Care Act, protections exist to ensure that higher risk, older enrollees are charged no more than 3 times as much as a healthy young adult.

Do you have any suggestions if all your doctors are not included in any of the plans?

Ensure you weigh the cost of in-network & out-of-network provider benefits. Identifying the plan that covers as many of your current providers as possible will help ensure your out-of-network costs are as low as possible. If you are in an employer-sponsored plan, consider discussing the plan’s network with someone in your HR department to help inform future benefit design. 

What if you and your spouse have enrollment dates that are different? Can you change your election before December 15?

It would be best to talk it out with a licensed social worker so you can discuss the best options for your family’s specific needs. You can call our helpline at 844-571-HELP to speak to a licensed social worker who can help.

State Exchanges

How do state exchanges work?

State exchanges work very similarly to federal exchanges, but they are run by your local state government. If you visit you should be able to find assistance. All state and federal exchanges adhere to certain regulations, although state exchanges have some degree of latitude in many areas. Keep in mind that patient protections that apply to the federal exchange plans also apply to state exchanges. Open enrollment is currently open for all state exchanges, but the deadlines vary.

Can I have a state and a federal exchange plan at the same time?

No, depending on the state you live in, you’ll be eligible for one or the other. You can visit to find out which plan you are eligible for.

Is it true that some state exchange plans don’t cover pre-existing conditions?

The Affordable Care Act remains the law of the land and pre-existing conditions are protected. Earlier this year, legislation was proposed that had the potential to eliminate these important protections, but the bills did not pass.

Costs and Access

How much should we expect to pay for a plan?

For federal exchange plans, depending on the plan you choose – bronze, silver, gold or platinum – you’ll pay a percentage of the yearly costs for your care. Your insurance company will pay the rest. To understand how you and your plan would split costs on the federal exchange, check out To learn about the basic costs for enrollment in Medicare, visit

Where would I look to understand prescription drug coverage offered by a plan?

Read the formulary as provided by your health plan to confirm that your medications are covered by the plan. You can refer to our toolkit to understand your formularies and the impact on your out of pocket costs, especially regarding biologics.

If my plan says it pays a percentage of drug costs, how do I calculate how much my out of pocket expenses will be, especially for expensive biologics?

You can refer to our toolkit, which will help you understand your out of pocket costs, especially regarding biologics.

What should I do if I encounter access issues once the plan year starts?

If you encounter issues with accessing medical care or treatment, we encourage you to talk with your benefits manager, HR department, or contact your insurance commissioner. The Arthritis Foundation has a resource online for you to learn about common reasons for claim denials and how to manage the appeal process in our toolkit, Your Coverage, Your Care.


Do you recommend traditional Medicare or one of the Medicare HMO/PPO plans?

You may find better value with Medicare Advantage (HMO/PPO) over traditional Medicare, depending on your health needs. At a minimum, the plans offered through Medicare Advantage must offer coverage comparable to original Medicare. However, Medicare Advantage can limit the choice of providers. Check out detailed Medicare cost information on For Medicare Part D, the prescription drug benefit, review the open enrollment guide available on the Arthritis Foundation’s website. 

Employer-Sponsored Insurance

Do you recommend having double coverage and selecting different plans for your spouse and personal employer?

It depends. You should review both you and your spouse’s unique medical needs and coverage benefits of the plans. Reach out to your employer’s HR department for guidance about group coverage. In addition, you may contact a licensed social worker so you can discuss the best options for your family’s specific needs. You can call our helpline at 844-571-HELP to speak to a licensed social worker who can help.

High-Deductible Health Plans 

What is a high-deductible health plan (HDHP)?

According to, an HDHP is a plan with a higher deductible than a traditional insurance plan. The monthly premium is usually lower, but you pay more health care costs yourself before the insurance company starts to pay its share (your deductible). An HDHP can be combined with a health savings account (HSA), allowing you to pay for certain medical expenses with money free from federal taxes.  Increasing numbers of patients are on HDHPs, sometimes by their choice and sometimes because it is the only option available to them through their employer.

How does a health savings account (HSA) factor into an HDHP?

An HSA is a type of savings account that allows you to set aside money on a pre-tax basis to pay for qualified medical expenses. A Health Savings Account can be used only if you have an HDHP. 

What do HDHPs mean for me and my chronic disease?

For patients with a chronic disease such as arthritis, treatment is ongoing, and out-of-pocket costs can often put medications out of reach. Many drug companies offer programs to help relieve the cost of arthritis-related medications, covering co-payments at the pharmacy (e.g., co-payment cards). However, this type of co-payment assistance is not unlimited and often has monthly or yearly limits.

Will co-payment assistance vary from plan to plan or manufacturer to manufacturer?

Check out our website to learn more about copayment assistance available from a manufacturer for your arthritis-related medication. Each HDHP plan is different, so make sure you contact your insurer to learn how they treat co-payment assistance under HDHPs.

What do I need to know about co-payment assistance with my HDHP?

If you have an HDHP, a health plan’s benefit design may only credit you with the amount of money you spent out of your own pocket, rather than permitting the value of co-payment assistance to be applied to your deductible or out-of-pocket maximum. We recommend going right to the source and asking your health insurer how co-payment assistance is applied. If you have health insurance through your employer, speak with your HR Department to understand your health coverage options and whether the health plans available utilize programs that would place limits on co-payment assistance.

What if I have other questions about selecting a health care plan?

The Arthritis Foundation has created a toolkit, Your Coverage, Your Care, to help you better understand health coverage options, determine how your current plan meets your arthritis care needs, and guide you through the claim denial process.

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