What a wild ride this year has been. It’s hard to believe we are already nearing the end. We all know what that means; it’s time to go shopping! No not the fun holiday shopping you’re thinking of. This shopping trip is for insurance. It’s scary; I get it. I’ve often felt like the mental strain of navigating the business side of diabetes was more overwhelming than actually keeping my numbers in control. Hopefully this blog can help calm some of the nerves and assist you during this year’s insurance shopping experience. If you need a refresher on insurance terms before we get started, check out CDN’s Insurance two-page guide.
“The Marketplace” allows you to shop and compare insurance plans when you do not have access to insurance through an employer or family member. The Marketplace is key in helping make healthcare accessible and bases the cost of insurance off household income. Because each state manages their own Marketplaces, these income ranges vary by state. Typically if your income falls below your state’s lower range, you qualify for free healthcare through your state’s Medicaid plans. If you fall into one of the other ranges, you will be shown plans at a lower cost than if you bought your own medical plan directly from an insurance company. The deductible, out of pocket maximum, and premiums will be calculated based on the income you entered. If your income is greater than the maximum income cap, you may still be able to shop plans on the Marketplace, but you will be shown plans at their full prices with no discounts.
"The Marketplace allows you to shop and compare insurance plans when you do not have access to insurance through an employer or family member."
The first step in purchasing insurance from the Marketplace is to visit https://www.healthcare.gov/ and enter your zipcode to browse plans.
You will be asked to provide your household size, age, and expected income. If you don’t have reliable income, this part may be difficult. While I was in college, my monthly income varied throughout the year - in the summer I often had full-time jobs or internships or jobs but during the school year I worked part-time. I typically used an average monthly income for what I thought I would make with a summer job in addition to my part-time school year job.
Based on the income and other demographic information you enter, you may be given an estimated cost savings and then shown plan options based on your information. If your income is in the lower range, you may only be shown your state’s Medicaid plan.
"You will be asked to provide your household size, age, and expected income. If you don’t have reliable income this part may be difficult."
If your income falls into another range, you will be shown plans based on your eligibility. These plans are in a three tier model; bronze, silver, and gold. Bronze plans often offer lower premiums with higher deductibles and out of pocket maximums. Gold plans are the opposite with higher premiums and lower deductibles and out of pocket maximums. Silver plans fall right in the middle, with medium premium costs and often medium deductibles and out of pocket costs.
If your income falls above the higher limit, you will be notified that you do not qualify for plan discounts through tax credits. However, you can still browse and apply for insurance plans through the Marketplace, they will just be displayed at full price. It may be beneficial for you to shop for plans through an insurance broker or directly with private companies as they might have more options available than those shown on the Marketplace.
When comparing plans on the Marketplace, I often disregard the Bronze plans all together. For those of us with chronic conditions, these plans are often just too expensive. However, just because I haven’t found them helpful for my situation, doesn’t mean they won’t work for you. I encourage you to do your own discovery of plans so you can make a fully informed decision about your coverage.
"When comparing plans on the Marketplace, I often disregard the Bronze plans all together. For those of us with chronic conditions, these plans are often just too expensive."
I will usually filter the plans by tier type, company, or cost, depending on my needs for the year. I will prioritize plans by insurance companies, if I know some work well with my current doctors or prescriptions; other times I filter by doctor to make sure I don’t have to switch up my care team. Then I compare plans based on the total cost of the plan. Because chronic health conditions require so much more care and attention, I often assume I will meet the plan’s out of pocket maximum before the end of the year. Making this assumption up front, while scary since that is a lot of money, it helps me plan my budget for the year.
To calculate the total cost of a plans, I use this formula: monthly premium x 12 + Maximum out of pocket. While not a fool proof method, it helps me see the maximum amount I might have to pay for healthcare for the year. Sometimes this narrows it down enough for me and I choose the least expense of the remaining options. I always pay attention to the deductibles, often the least expensive plans have higher deductibles that I will meet easily within the first few months of the year. If I don’t have enough money in my savings to cover the deductible in the first part of the year, I will look at a plan that may cost more money over the course of the year but less money up front - typically Gold tier plans.
When reviewing the plans, it is also a good idea to check all the documents. These can include an explanation of benefits, which outlines co-pay amounts. If a formulary is available, review that to see which insulins and diabetes supplies are preferred. This can help you rule out plans that may not cover the supplies for your preferred CGM or insulin pump.
"Because chronic health conditions require so much more care and attention, I often assume I will meet the plan’s out of pocket maximum before the end of the year."
I find the silver plans are overall less expensive for the full year than the Gold plans. Even though the Gold plans have lower deductibles and out of pocket maximums, their higher premiums can make them less affordable. But again, carefully review the plan results for your state, your projected healthcare needs, and your budget for the next few months, before you decide on a plan.
After deciding which plan you want to enroll in, you will have the option to accept the tax credit discount or only part of the discount. It may be in your benefit to only accept part of the tax credit. If you think your income may increase throughout the year (through bonuses or raises), accepting only part of the credit will insure you do not have to pay a fee when you do your taxes for that year.
Another way to help avoid unforeseen charges when you file your taxes, is to keep your income up to date in the Marketplace. If at any time in the year your income changes more than a few hundred dollars, you should update the amount on file in the Marketplace. This can be more than a little nerve racking - if your income changes enough you might become ineligible for that specific plan at that rate. This is why it is very important to try to be as accurate as possible with your income estimate at the beginning of the year when you enroll. Following the average monthly income estimate and estimating on the higher end, can help avoid having to make changes mid-year.
Yes, these shopping trips are an overwhelming process, but luckily you don’t have to complete it alone. There are several organizations that are established within local state and city communities that can work with you to find the best plan to meet your healthcare needs. You can search local agencies and organizations on localhelp.healthcare.gov/. Just remember -- the earlier you can start your research and enrollment process, the better.