Annual Open Enrollment

Posted by Phil Dougherty
October 30, 2015

The annual open enrollment period is upon us when you can evaluate plans in the new insurance marketplace and replace your existing policy if you so choose. Like in previous years there will be mandated changes to standard plan benefits for the next plan year.  These are the most notable:

  • Embedded Out-of-Pocket. In ACA-compliant plans (Affordable Care Act) the annual Out-of-Pocket (OOP) maximum for self-only coverage applies to all individuals—including those enrolled in two party or family plan coverage. This means that no individual can be required to pay more in annual cost-sharing than the ACA individual OOP limit, even though a family unit as a whole may be subject to the higher overall OOP maximum. In other words, the self-only ACA OOP maximum is “embedded” in the other-than-self-only coverage.
  • Prescription Medication Benefit Changes. In 2016, all metal-tier plans will now have a maximum monthly out-of-pocket maximum on specialty drugs (once the pharmacy deductible is met). For the Bronze standard plan there is a $500 monthly per prescription maximum and for Silver, Gold, and Platinum the monthly out-of-pocket maximum is $250 per prescription after the pharmacy deductible is met.
  • Bronze Level Plan Change. The first cumulative three visits are again not subject to the deductible, but can now include a specialist visit in addition to primary care, mental health and urgent care visits. In addition, laboratory work is not subject to the deductible.

Note: In the private marketplace there are other options available in each benefit category, which may have slight changes from the standard benefit design.

If you need assistance in evaluating plans and making a plan change, or enrolling for the first time, don’t hesitate to contact us.

Phil Dougherty