The Health Insurance Marketplace & People with Diabetes
Individuals and families can buy health insurance through a Health Insurance Marketplace (Marketplace) available in every state.
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 way for individuals, families, and small businesses to 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.
When Can I Buy Coverage in the Marketplace?
Anyone can shop for coverage and purchase or change Marketplace plans during the annual open enrollment period which occurs every fall. After the open enrollment period ends, you must wait until the next open enrollment period to buy insurance in the Marketplace unless you qualify for a special enrollment period.
What if I am already enrolled in a plan I bought in the Marketplace?
Before open enrollment starts, you should get a notice from your plan about renewing your coverage. Open enrollment provides a new opportunity to compare other plans available to you and make sure you are getting all the financial assistance you qualify for. During this time, you should contact the Marketplace to make sure you are still getting the right amount of tax credit to buy a plan and see if you are enrolled in the best plan for you. Since health plans and plan prices change every year, you may find a new plan that meets your needs and is more affordable. Each year, plans can change their drug formulary (list of covered drugs) and/or network of health care providers so be sure to double check that your drugs and health care providers will still be covered and what it will cost you if you want to stay in the same plan.
In 2016, Marketplaces in most states will have online tools to help you see which doctors are covered in plans and whether a health plan covers a particular prescription drug. Visit www.healthcare.gov to search for plans available to you in your state’s 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), most TRICARE plans 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 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).
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 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 chart below gives examples of two different family sizes and the household incomes which may qualify for financial help:
Who is Eligible for Premium Help?
|Family Size||Household Income*|
Who is Eligible for Cost-Sharing Help?
|Family Size||Household Income*|
*Note: The income amounts are based on 2016 numbers. They will likely be slightly higher for 2017 and may vary some depending on your state.
Eligibility for financial help will vary depending on your state, family size, and projected 2017 income. In addition, many of those with incomes below the levels listed here may be eligible for coverage by Medicaid. 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.
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.
How Can I Sign Up for Coverage in the Marketplace?
Individuals can shop for and enroll in health insurance through the Marketplace from November 1, 2016 through January 31, 2017. The start of coverage under the plan depends on when you buy it, with January 1, 2017 as the earliest start date. After January 31, 2017, the annual open enrollment period will occur each fall 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 the annual open enrollment period ends, 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 marriage. 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 are trained people called "Navigators" and other assisters 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 or by searching on the following website: localhelp.healthcare.gov.
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).