The Ultimate Guide to Health Insurance
Choosing a health plan is complicated. We’re here to help simplify it
Navigating the maze of insurance options can be confusing. Whether you’re covered through your job or through the government’s marketplace of plans, there’s plenty to sort out, especially when you have a chronic condition such as diabetes. On these pages, answers to often-asked questions will help you find the plan that best suits your needs and your budget.
What is open enrollment?
Around the end of every year, you have a window of opportunity to sign up for the next year’s insurance coverage. Workplaces can offer new coverage at any time of the year, but generally the sign-up period falls between November 1 and December 15. The time frame is the same for state and federal marketplaces. You can also sign up for a new plan if you have a qualifying life event, such as the start or end of a job.
If my employer offers insurance, what should I know about the various plans available?
Workplaces typically offer plans that involve either health maintenance organizations (HMOs) or preferred provider organizations (PPOs). Some employers may also offer a point-of-service (POS) plan or exclusionary provider organization (EPO) plan.
- With an HMO plan, your monthly cost will be less, but the plan covers only providers who are within your network. Your primary care provider must give referrals for all your specialist visits. You’ll need to make sure members of your diabetes care team—such as your endocrinologist, diabetes educator, and dietitian—are in network, or you’ll pay out of pocket to see them, sometimes hundreds of dollars.
- A PPO plan is usually more expensive, but visits to out-of-network providers are covered at a higher rate, and in-network visits are often cheaper. For example, your insurance may cover 80 percent of the cost of a visit to an in-network provider and 40 percent of an out-of-network visit. Plus, with a PPO you don’t need to see your primary care provider for a referral in order to see a specialist, which can save you time and the cost of a co-pay.
- POS plans are comparable to PPOs, but they require a referral before you can see a specialist.
- An EPO plan is like an HMO in that you must stay within network—anything out of network means you’ll pay the full cost. But unlike an HMO, you don’t need a referral to see a specialist.
Choosing a plan often comes down to cost and flexibility. If you love your current diabetes care team members but they’re out of network, you might opt for a PPO that will cover out-of-network visits instead of a cheaper HMO, which would require you to switch providers. If you see a lot of specialists—an endocrinologist, cardiologist, and neurologist, for instance—you may not want to go through a primary care doctor first, so a PPO or EPO could be a good fit. But if you’re on a tight budget, an HMO may be the best option; while less flexible, it’s also cheapest.
I don’t get insurance through work. Where can I go for coverage?
Start at healthcare.gov. Once you enter your ZIP code, the site will redirect you to your correct marketplace. There you’ll find plans that range from bronze (lower monthly costs, higher deductible) to platinum (higher monthly costs, with low to no deductible). While plans vary in cost, every plan on a state or federal marketplace must include the essential health services outlined in the Affordable Care Act: preventive health care, chronic disease management, maternal care, mental health care, and prescription drug coverage. You can also get coverage through the marketplace if you’re between jobs.
In addition, you can buy insurance directly from insurance companies or qualified brokers. “There are a few drawbacks to this method,” says Rosemarie Day, MPP, founder and CEO of the health care consulting firm Day Health Strategies and the founding deputy director and former chief operating officer of Massachusetts’ state marketplace, The Health Connector. “You don’t see the full array of plan options in front of you; you aren’t eligible for subsidies, which can reduce your monthly costs; and you might be pushed into a plan that doesn’t cover what you need or that isn’t right for you, depending on the financial incentives of the agent or broker.”
How do I know if my medications or devices are covered?
Every insurance company has a list of the medications covered each year. You can often find them by searching online using an insurance company’s name and “drug list” or “medication formulary,” says Amy Hess Fischl, MS, RDN, LDN, BC-ADM, CDE, a certified diabetes educator at the University of Chicago Kovler Diabetes Center. The formulary also shows in which tier drugs are classified; those in the lowest tier are cheapest and often generic, while those in the top tier are the most expensive. Be sure to check the formulary at each enrollment period; they frequently change. Devices are considered durable medical equipment. Those lists are sometimes harder to find, but you can request one from a company when you’re researching coverage.
I’m torn between the plan with the high premium and low co-pay and the one with the lower premium and high co-pay. Which makes more sense if you have diabetes?
It depends on your budget. A higher premium might mean more up-front costs each month, but you’ll pay less for each clinic visit and for your medications and devices. It’s important that people with type 1 or type 2 diabetes (or those at risk for type 2) run the numbers on their available options. Fischl recommends asking these questions of any plan you consider:
- What will my deductible be?
- What are my costs and co-pays?
- Are the medications, devices, and supplies I’m using on the least-expensive co-pay level (tier)?
- What’s my monthly premium?
- Am I able to have a health savings account or flexible spending account (see “Flexible Spending Accounts: 4 Fast Facts”)?
- Is diabetes education covered?
This is complicated! Who can help me?
“Buying health insurance is complex, perhaps as complex as filing taxes,” says Dave Chandrasekaran, a health policy consultant and volunteer certified application counselor in Washington, D.C. “Some people can do it on their own, but many people need help.”
For plans in a state or federal exchange, an enrollment assister, such as a certified navigator or certified application counselor, can help you compare the different plans. They’re trained to be unbiased, and there’s no charge for their services. Enrollment assisters can help consumers feel educated enough to make the best decision based on their specific needs.
For plans you buy directly from an insurance company, an insurance agent or broker is licensed by your state and paid by insurance companies. They can recommend plans to you, and in most states they’re required to act in your best interest.
Find any of these helpers in your area by visiting localhelp.healthcare.gov.
If you get insurance through your work, ask human resources to connect you to a broker, who can walk you through the health plans available to employees.
What if I can’t afford insurance?
- People 65 and older are eligible for Medicare, a federal health insurance program.
- Younger people with certain disabilities or end-stage kidney disease can also enroll in Medicare.
- People with low income may qualify for Medicaid, a federal insurance program. Eligibility varies by state.
- Low-income parents can enroll their kids in the Children’s Health Insurance Program (CHIP).
Find out if you qualify for these programs at healthcare.gov. If you still can’t afford insurance, look to community health centers for low-cost health care. They charge based on your income and offer services such as primary care. Find one in your area at healthcare.gov/community-health-centers.