What is the health insurance marketplace, and how do I know if I am eligible for coverage?
The health insurance marketplace – sometimes referred to as the health insurance exchange – is where consumers can purchase health insurance plans that comply with the patient protections in the Affordable Care Act.
The marketplaces are an important resource for individuals and families who don’t already have high quality coverage through Medicaid, Medicare, or an employer. Many of those individuals and families – including some with employer-sponsored coverage – will qualify for financial assistance from the federal government to help pay for coverage purchased through the marketplace. That assistance can dramatically reduce monthly premiums and, for certain consumers, their out-of-pocket expenses as well. To find out more, visit www.healthcare.gov.
The Marketplaces can also help you determine if you or members of your family may be eligible for Medicaid. You can enroll in Medicaid anytime through the year, if you're eligible.
How do I enroll in coverage?
The best place to start is www.healthcare.gov. This website is hosted by the federal government and serves as the entry point for consumers who want to purchase health insurance coverage through the marketplace. If you live in a state with its own marketplace, www.healthcare.gov will transfer you to the website for that state’s marketplace.
The marketplace sites will calculate based on your income whether you qualify for financial assistance to help pay for your coverage or whether you’re eligible for coverage through Medicaid.
When is open enrollment?
Open enrollment is an annual period during which consumers select their health insurance plan for the following calendar year. The open enrollment period runs from November 1, 2021 to January 15, 2022 federally and in most states, though some states stop at December 15th.
Can I be denied coverage based upon my cancer diagnosis?
No. According to the Affordable Care Act, you cannot be denied coverage or charged a higher premium for your coverage due to any pre-existing condition, including cancer. However, this protection is only guaranteed in plans that adhere to the Affordable Care Act, like the plans sold through the marketplace.
Remember there are many other kinds of products for sale that might be called “health insurance” but which don’t adhere to the patient protections that are in the Affordable Care Act. These products can include, for example, “short-term limited-duration” plans.
How many insurance choices will I have?
This will vary depending on where you live. In some states or regions, there may be multiple health insurers offering a variety of plans. In other places, there may only be one or two insurers offering plans.
The choices will be broken down into four “metal tiers:” bronze, silver, gold, and platinum. Bronze plans tend to offer less coverage in exchange for a lower premium, while platinum plans typically provide robust coverage but come with a higher premium. Platinum plans are not available in all areas.
What is cost-sharing?
Typically, a health insurance plan will require you to pay “cost-sharing” – that is, a portion of the total cost of your care. Cost-sharing might include copays, deductibles, and coinsurance.
A deductible is the amount of money that a consumer must pay out-of-pocket before the plan begins paying for any care. Depending on the plan, this could mean you have to pay the full cost of certain office visits, specialty services, or prescription drugs until you’ve met your deductible. For instance, if your plan has a $1,000 deductible, you are expected to spend $1,000 out of your own pocket for covered benefits and services before your plan begins to make payments on your behalf. Deductibles have grown significantly in recent years, and consumers should make sure they understand the deductible for each plan they are considering. Note that some plans include more than one deductible.
Copays are flat dollar amounts that a consumer might be required to pay in order to see a doctor, for example, or to purchase a prescription medication. Coinsurances are different than copays because they require the consumer to pay a percentage of the total cost associated with a doctor visit, for instance, or a prescription drug. Due to regional variations in cost and the high prices of many services and medical products, coinsurances can be difficult to estimate in advance and often mean very high out-of-pocket costs.
Deductibles and coinsurance are important for blood cancer patients to consider when shopping for health insurance coverage, as these two factors will enable patients to better understand the total costs they will be expected to pay in addition to a plan's premium.
What I if decide in the middle of the year that my coverage isn't adequate for my healthcare needs?
The open enrollment period is the only time during the year when you can switch coverage. If you decide during the year that your coverage isn't adequate, you will not have an opportunity to switch to a different plan until the next open enrollment period. The only exception to that is if you experience certain life-changing events during the course of the year, such as marriage, divorce, pregnancy, changes in income, the loss of employer-provided coverage, or a qualified hardship.
How can I find out if the particular medications I take to treat my disease are covered and what the cost of these medications will be?
You will need to review the documents provided for the health insurance plans you are considering. Look for each plan’s formulary – the list of drugs covered by the plan – and search for the name of each medication you take. Cost-sharing for each medicine should be listed on the formulary as well.
How do I know if I qualify for financial assistance from the government?
If you provide information during the enrollment process regarding your household income, the marketplace website will automatically determine whether you qualify for financial assistance. This may include a tax credit to help pay your premiums or eligibility for a plan that has reduced cost-sharing requirements.
If I receive copay assistance from LLS today, may I continue to receive it if I purchase coverage through the marketplace?
Yes, you may still be eligible to receive this form of assistance from LLS, provided you still qualify under the conditions of the LLS Copay Assistance Program.
For assistance contact an LLS Information Specialist.