The Health Insurance Marketplace & People with Diabetes

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Starting on October 1, 2013, individuals and families have a new opportunity to buy health insurance through a Health Insurance Marketplace (Marketplace) available in every state.

Coverage purchased in the Marketplace will be effective as early as January 1, 2014.

Starting in 2014, all new health insurance plans, whether sold inside or outside the Marketplace, cannot deny coverage, charge more, or refuse to cover treatments because you or someone in your family has diabetes.

People who meet certain income requirements may also qualify for help paying their premiums and other costs for plans purchased in the Marketplace.

What is a Health Insurance Marketplace?

A Health Insurance Marketplace is a new way individuals, families, and small businesses can shop for – and compare – various private health insurance options all in one place.

Plans offered in the Marketplace must meet certain requirements for benefits, consumer protections, and cost to the consumer.

Marketplace plans are separated into four different categories: Bronze, Silver, Gold, and Platinum. These categories are based on an average of how much the plan pays for covered benefits. 

In general, moving from Bronze to Platinum, out of pocket costs get lower while premiums tend to get higher.

Who Can Buy Health Coverage in a Marketplace?

Generally, anyone who buys health insurance on their own can buy it through a Marketplace.  However, only those who meet certain income requirements – and who do not qualify for affordable job-based health coverage or certain other types of coverage – are able to get financial help paying for a plan purchased in the Marketplace.

Can I Still Buy Health Insurance Outside of the Marketplace?

Yes. You can still buy health insurance directly from an insurance company outside the Marketplace, but those plans may not meet all of the same minimum requirements as plans sold through the Marketplace, and you will not be able to get financial help paying for health insurance you buy outside the Marketplace.

Do I Have to Have Health Insurance?

Starting in 2014, most individuals must have health insurance or pay a tax penalty in the following year, unless they qualify for an exemption. Plans purchased in the Marketplace will meet this requirement, and so will job-based coverage, Medicare, Medicaid, state Children’s Health Insurance Programs (CHIP), TRICARE and the Veterans health care program.

If you get insurance from another source make sure it meets minimum requirements to avoid the tax penalty. 

What If I Already Have Health Insurance?

If you like your current insurance you can keep it, but check to make sure it meets minimum requirements to avoid the tax penalty.

The Marketplaces will be a new way to get health insurance, including insurance for people with diabetes who previously had trouble obtaining affordable health insurance that meets their needs. Contact your state's Marketplace to see what options are available to you.

 

What Benefits Will Be Covered In the Marketplace?

Health insurance sold in the Marketplace must at least cover a set of “essential health benefits.” This includes: doctor’s office visits; emergency room services and hospitalization; pregnancy and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative services and devices; laboratory services; preventive services; chronic disease management; and children’s health services (including oral and vision care).

 


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The specific benefits covered and amount you pay for these services can vary by plan. When shopping for a health plan, it is important to ask if the plan covers the diabetes supplies, services, and perscription medications you need, and what it costs. If you want to keep your current health care providers, check to see if they participate in the plan.


 

Can I Be Denied Coverage or Charged More Because of My Diabetes? Are There Other Protections I Should Know About?

You cannot be denied coverage or charged more because you have a pre-existing condition such as diabetes.  This is true for new plans sold inside and outside the Marketplace. Plans can only set higher premiums based on age, tobacco use, family size, and geography. 

In addition, plans must limit how much you pay out-of-pocket for benefits and must provide certain health services aimed at preventing disease at no charge. Plans cannot set a dollar limit on the amount  the insurance company will spend on “essential health benefits” either in a given year or during the entire time you’re enrolled in that plan.

However, plans can still impose other types of limits on benefits, such as number of doctor visits, number of prescription drugs, or days in the hospital.  Visit www.healthcare.gov or see our fact sheet: “Health Insurance Update: Protections for People with Diabetes” to learn more about these protections.

How Does the Financial Help Work?

U.S. citizens and lawfully-present immigrants with certain household incomes may qualify for help paying premiums through a newly created tax credit, with the most help for those with the lowest incomes. 

In addition, people with low incomes may also qualify for cost-sharing help to reduce out-of-pocket costs, such as deductibles and co-pays, for essential health benefits.

The information below gives examples of two different family sizes and the household incomes which may qualify for financial help:

Eligibility for Medicaid varies by state. Contact your state Marketplace for more details on how financial help works, and to learn if you are eligible for financial help or Medicaid.

 


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If you take the tax credit, changes to your family size or income, a new job that offers health insurance could mean you are getting the wrong amount of tax credit. To be sure you get the right amount and won’t have to repay any of the credit, it is important to call your state Marketplace when you have changes during the year.


 

How Can I Sign Up for Coverage in the Marketplace?

Individuals can shop for and enroll in health insurance through the Marketplace from October 1, 2013 through March 31, 2014. The start of coverage under the plan depends on when you buy it, with January 1, 2014 as the earliest start date. After March 2014, the annual open enrollment period will run from October 15th through December 7th for coverage starting the following year.

Through the Marketplace you can fill out an application either online, over the phone, or in person to find out whether you are eligible for financial help paying for private health insurance, or if you’re eligible for coverage under your state’s Medicaid or CHIP. Once your eligibility is determined, you can compare plans and buy one that meets your needs.

After March 31, 2014, you must wait until the next open enrollment period to buy insurance in the Marketplace unless you qualify for a special enrollment period because of a qualifying life event like a job loss, birth, or divorce. Plans sold outside the Marketplaces may be available year-round, but you will not be able to get help paying for your insurance. You can apply for Medicaid or CHIP at any time during the year.

 

What Do I Do If I Need Help Finding and Choosing a Health Plan?

There will be trained people called “Navigators” to help individuals understand their coverage options and the enrollment process. You can access this free individual assistance to help you choose a plan and enroll by contacting your state Marketplace.

Where Can I Get More Information About the Plans Available to Me?

  • Contact your state Health Insurance Marketplace.  You can find contact information for the Marketplace in your state by visiting www.healthcare.gov or by calling 1-800-318-2596 (24 hours a day/7 days a week).
  • Assistance is available in multiple languages by calling 1-800-318-2596.
  • You can also read more about Marketplaces and health reform on www.healthcare.gov. To learn more about health reform and people with diabetes see our fact sheet: “Health Insurance Update: Protections for People with Diabetes” at www.diabetes.org/HealthInsuranceUpdate2014 or by calling 1-800-DIABETES (342-2383).
  • Last Reviewed: October 1, 2013
  • Last Edited: January 29, 2014

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