Individuals and families that do not have access to health insurance from an employer and do not qualify for public programs, such as Medicaid or Medicare, may wish to purchase a health plan on their own in the individual insurance market. In the past, many people with diabetes and other chronic conditions who have tried to buy an insurance plan on their own have had a hard time finding insurance that will accept them, that is affordable or that provides adequate coverage.
As a result of the Affordable Care Act (ACA), this has changed.
- Coverage for young adults: Young adults can stay on their parent's insurance plan until age 26 as long as the policy covers dependents.
- Coverage for people with diabetes: Starting in 2014, new individual plans are not allowed to deny individuals coverage or charge them more because they have diabetes, or any other pre-existing condition. Also, these plans cannot exclude coverage in the insurance policy for treatment of a pre-existing condition, such as treatment for diabetes. These protections have been in place for children since 2010.
- Essential health benefits: Starting in 2014, a minimum set of "Essential Health Benefits" like hospitalization, prescription drugs, preventive services, and chronic disease management must be covered in all new individual and small group plans, including all plans sold in the Health Insurance Marketplaces.
- Summary of benefits and coverage: Individuals have the right to get a plain language summary (called a Summary of Benefits and Coverage, or SBC) of a health plan's benefits to help them better understand the plan's coverage and compare plans. Plans must provide the SBC when a person is shopping for coverage, when there is a major change in benefits, or anytime a person asks for it.
Learn more about health insurance protections under the ACA which impact people with diabetes by calling 1-800-DIABETES (342-2383) and asking for our fact sheet "Health Insurance Update: Protections for People with Diabetes". You can also learn more at www.healthcare.gov.
Health insurance marketplaces
A Health Insurance Marketplace (Marketplace) is available in every state where individuals and families can buy health insurance. Plans in the Marketplace must meet certain requirements for benefits, consumer protections, and cost to consumer.
Individuals and families with incomes below a certain level who do not have an offer of affordable insurance from their employer and do not qualify for certain other types of coverage may be eligible for financial help to purchase insurance.
Individuals can shop for and enroll in health insurance through the Marketplace from November through December every year for coverage starting January 1, (Some states may allow more time to enroll —check with your state Health Insurance Marketplace).
Once the annual open enrollment period ends, you must wait for 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.
When you fill out an application in the Marketplace, you will be informed about your eligibility for financial help to purchase insurance, or if you're eligible for coverage under your state's Medicaid program or Children's Health Insurance Program (CHIP). Once your eligibility is determined, you can compare plans and buy one that meets your needs.
Consumer assistance is available online, over the phone, or in-person. There are trained people called "Navigators" and other assisters to help individuals understand their coverage options and the enrollment process. Assistance is available in multiple languages.
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.
For more information on the Marketplace and Navigators and other assisters in your state, call 1-800-318-2596 or visit www.healthcare.gov. The American Diabetes Association also has a fact sheet on the Marketplaces available at www.diabetes.org/HealthInsuranceMarketplaces or by calling 1-800-DIABETES (342-2383).
Other private insurance options for individuals and families
In most states, a person may choose to buy health insurance directly from an insurance company outside the Marketplace. Plans sold outside the Marketplaces are also available during the open enrollment periods for the Marketplace (and may be available year-round depending on whether insurers choose to sell them), but you will not be able to get the financial help paying for your insurance - financial help is only available through the Marketplaces.
Starting in 2014, all new individual 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.
Due to a federal announcement in 2014, some people may be able to continue to reenroll for a few more years in the individual health insurance policy they had before 2014. However, the insurance policy will not provide all of the rights and protections that new individual policies sold inside and outside the Marketplace must follow starting in 2014.
When shopping for a health plan, it is important to check if the plan covers the diabetes supplies, services, and prescription drugs you need, and what it costs. If you want to keep your current health care providers, check if they participate in the plan.
For Information about job-based coverage and what to do if you lose your job, visit www.healthcare.gov.
Other coverage options that may be available
Medicaid is a state-run program providing medical coverage for individuals and families with low incomes and resources. It is up to each state to set its Medicaid program eligibility.
Contact your state Medicaid program or the state Health Insurance Marketplace for more information on who is eligible for Medicaid in your state.
State children's health insurance program
The Children's Health Insurance Program (CHIP) is designed to provide coverage to children and teens up to age 19 whose families may have too great an income or assets to qualify for Medicaid, but who may not be able to afford health insurance.
Contact the CHIP program in your state or the state Health Insurance Marketplace for more information.
State high-risk pools
Some states have or had high-risk pools that provide coverage to people with medical conditions. Often people in high-risk pools were unable to purchase coverage in the individual insurance market in the past because of a pre-existing condition.
Coverage purchased through a high-risk pool can be very expensive and there may be a waiting period for coverage of preexisting conditions unless you've had prior coverage.
High-risk pools don't have to comply with the new ACA consumer protections, so, for example, they may continue to have annual or lifetime dollar limits, and don't have to limit out-of-pocket costs.
Individuals and families can now buy health insurance through a Health Insurance Marketplace available in every state as a result of the ACA. Generally, individuals and families can only buy a plan in the Marketplace during the open enrollment period every fall, unless they qualify for a special enrollment period.
As a result of these new health insurance changes, most states have closed their high-risk pools and transitioned enrollees to other coverage. If you are currently enrolled in a high-risk pool, you can contact your state Health Insurance Marketplace to see what new options are available to you and if you qualify for financial help for plans purchased in the Marketplace.
Individuals with disabilities
Individuals and families can buy health insurance through a Health Insurance Marketplace available in every state. Starting in 2014, all new individual 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.
Other coverage options for people with disabilities may include:
Individuals with disabilities who are low income may qualify for their state's Medicaid.
Contact your state Medicaid program or state Health Insurance Marketplace for more information on who is eligible for Medicaid in your state.
A person with a medical condition that has prevented them from working or is expected to prevent them from working for at least 12 months or end in death may be able to get Social Security disability benefits. After a person has received Social Security disability benefits for 2 years, he/she can get Medicare coverage even if under age 65.
For more information about Social Security disability benefits, or to learn if you qualify for Medicare, please call the Social Security Administration at 1-800-772-1213 or your local Social Security office.
Note: Some people with disabilities qualify for both Medicare and Medicaid.
Local community health clinics and pharmacies
If you or your loved one is unable to see a physician due to the cost of care or unable to afford medications, there may be a local community health clinic or pharmacy in your area. These clinics generally are free to patients or require a very small fee. Visit https://findahealthcenter.hrsa.gov/ to find a clinic or pharmacy in your area.
Requirement for individuals to have health insurance
Starting in January 2014, most individuals must have health insurance that is considered "minimum essential coverage" or qualify for an exemption. Otherwise, the individual will owe a tax penalty during the following year.
Any job-based plan as well as plans purchased in the Health Insurance Marketplaces, Medicare, Medicaid, state Children's Health Insurance Programs (CHIP), most TRICARE plans and the Veterans health care program, and certain other coverage meet this requirement.
If health insurance is not considered affordable for an individual, that person will qualify for an exemption from the tax penalty. Individuals who are uninsured for less than three consecutive months of the year also will qualify for an exemption from the tax penalty.
Other exemptions exist. Learn more about the individual requirement at www.healthcare.gov.