Health insurance is a large and complicated issue in the US. I want to talk about the practical considerations about health insurance and health insurance choices.
Choosing your health insurance program can have a dramatic effect on your monthly expenses and your quality of life – so doing a bit of research and work now may save you a lot of stress later in the year! Trust me, when managing a serious illness or injury, this can make or break you!
When can I select or change my insurance?
We actually are near the end of the window for insurance open enrollment now(ends December 15th this year) – for most government associated insurance(Medicare and the insurance available through the Affordable Care Act). Most private insurers also have an open enrollment period at or around the same time – with all insurance plans selected going into effect on January 1. If you are on Medicaid double-check this – here in New Jersey, Medicaid open enrollment is at the same time, but I know that in Michigan open enrollment is in August for some reason.
It is possible to get insurance at other times of the year, but those opportunities are associated with major life changes(aka qualifying life events).
Medicare is also time-dependent, if you have Medicare, it either starts when you reach 65, or 24 months after social security agrees that your disability started. You generally can select your coverage when you qualify, but if you want to change it, you need to wait until the next open enrollment period.
If you are eligible for both Medicare and Medicaid, you often can change your plan at any time, but otherwise, you are stuck with your plan.
Medicaid is generally income-dependent, and so is only provided if you can prove your need and income limitations or are currently on Supplemental Security Income(SSI).
While Medicare and many private insurance providers are national programs, Medicaid is completely controlled and operated at the state level, so the differences between who is eligible varies dramatically by your State of residence.
Precise rules for eligibility also vary by state, so if you are looking to apply for Medicaid, you need to find out details about your state’s rules and qualifications.
You can apply for Medicaid at any time of the year, but they may assign you to a provider when you get it – and you can only change providers during open enrollment.
Now I’m dealing with a disability – what kind of insurance should I have?
So people with a more white-collar history likely have always or mostly had insurance – initially through parents, then later through work or school.
For many people though, insurance might not have been an option or had such high deductibles that it was practically useless. So, if you have little previous experience with insurance, insurers, and requesting or selecting coverage, it’s even more important than ever for you to find an insurance program that you can use.
For people whose employers(or spouse’s employers) provide insurance, this is often your best, and default, option.
Often employers will have multiple plans to choose among, which is where things can get confusing. There is always a lot of information on these forms – and often the fine print can make things more challenging.
You do often have the right to go onto COBRA for up to 18 months after losing your job.
COBRA allows you to keep the insurance coverage even though you no longer are an employee. It usually is much more expensive than what you pay when you cost-share with your employer(it’s often close to $800 or so per month, rather than something near the low hundreds).
You do need to call your insurance and do paperwork associated with using COBRA – usually, that information is included in paperwork involved in your separation or is mailed to you shortly after your job loss.
Since COBRA is often associated with a loss of income(death of a spouse or loss of job are the two most common reasons to use COBRA), it can be very challenging to maintain your benefits through it.
However, it can be useful to cover you while you manage your life changes and/or look for a better option. Better options are situation-dependent, but may be a new job with new insurance, Medicare, Medicaid, or coverage through the ACA.
If you are supporting yourself and have lost your job due to your disability, or if your spouse/partner’s/parents insurance cannot cover you for whatever reason, it’s time to find a reasonable alternative coverage.
Getting onto Medicare takes a lot of time. It can take years to be awarded Supplemental Security Income(SSDI), and Medicare doesn’t start until 24 months after onset of disability(which may or may not have passed while you were waiting for coverage).
Otherwise, you age into Medicare at 65 if you or your spouse has the appropriate work history. Even if Medicare is your eventual goal, you likely will need another form of insurance to get you through until you have Medicare coverage.
The ACA marketplace is now an option for people with reasonable income who don’t otherwise get insurance. The link provided will let you estimate your coverage costs and search for an appropriate plan that fits your needs.
Medicaid is an insurance safety net for low-income individuals, especially children(CHIP is the name of the children’s program, at least in New Jersey), pregnant women, and people with disabilities.
Applying for Medicaid is generally quicker than Medicare(you may still wait a month or two, but not much more than that), but you do need to fit your state’s qualifications. You can also get quality information from Medicaid.gov.
If you are struggling financially and have applied for Supplemental Security Income (SSI) or SSDI but are waiting for a response, applying for Medicaid is a very reasonable thing to do.
While you are waiting for something or if you are stuck without insurance, there are some clinics out there(like planned parenthood) that will provide services on a sliding scale if needed, and most larger hospitals have charity care programs.
However, especially if you are managing a mystery condition or require medication on a regular basis, it’s vital to get insurance as quickly as you can.
Most health insurance plans basically cover your medical costs – they often do not include, for whatever reason, vision-related expenses, and dental-related expenses.
Sometimes these are add-ons to a plan, and generally, these are optional.
In an ideal world, an adult with good teeth should have their teeth cleaned about once a year(with a history of dental problems it may be more often or more expensive dental work might be needed at some or most visits).
If you do not have a history of teeth issues and lead a reasonably low-risk life, you’re probably better off not getting the insurance, and just paying for cleanings every year or so(a cleaning will probably cost you $100-200), but if you suspect or anticipate challenges you may want to look into the details of your dental insurance options.
Just bear in mind that unless your insurance specifically says it covers dental appointments, this will likely be a (small) extra expense.
Vision is also often not covered. If you haven’t historically needed glasses and don’t expect that to change in the next year or so, you’ll probably be okay without vision coverage – you do want to see an ophthalmologist every couple of years if possible just to make sure that your vision is good and your eyes are healthy.
If you do need glasses or contacts, most vision coverage includes a stipend for the purchase of glasses or contacts – the specifics vary, but many programs do provide $100-200 towards a new pair of glasses or contacts as well as covering vision-related medical expenses. In some cases that stipend is only available every two years, but it’s annual for many.
I haven’t had either coverage in years, but I also know that I have never had a cavity in my life, and while I do need glasses, I only tend to buy a new pair every two or three years, which likely averages out to a wash financially.
Getting help choosing your plan
Fortunately, you may not need to go through your options by yourself! There are assistance programs out there that can help guide you through your decision-making process, but you will need to seek them out, and often make an appointment.
Your local foodbank or other space that provides assistance to low-income people may run programs to help you select the insurance that makes sense for you – do a search online for your town, county, or state and ‘ACA Navigator’
The navigators are designated people to help you with your plan selection, but they cannot suggest a particular company/plan. This is generally a better option as it lets you see your options but they do not pressure you to choose one plan over another.
If you are on Medicare, there is the State Health Insurance Assistance Plan(SHIPs) programs. This is a free service for all Medicare users. Another resource is https://www.seniorsresourceguide.com/directories/National/SHIP/
Health insurance is always about gambles and risks.
Not having health insurance is the biggest gamble with the highest risk. This is followed by having ‘catastrophic coverage’, which only helps if you have a major emergency!
Your other options are smaller risks, but you need to think through and decide how much coverage and how high a premium and deductible you can afford, and what you are willing to pay to keep yourself alive and as healthy as possible!
Conclusion: Health Insurance has many options
When you are living without chronic or disabling conditions, insurance may seem like a luxury item that might be beyond reach. Once you are managing a disabling condition, though, the definition of necessity often changes, and insurance is one of those options that become essential – and often right when your finances are also contracting and your expenses are increasing.
Selecting health insurance can be a scary and stressful experience, especially if you are unfamiliar with the terms, definitions, and costs involved. It is necessary though!
Seeing doctors is an expensive process, but the decisions you make in choosing your insurance coverage can help reduce those costs and help you to find the right professionals for you to see, and expand (or contract) your options – in terms of where you go, who you see, and what you take, all of which can be essential parts of your recovery or management process.
Vision and dental coverage are often separate expenses and while your health insurance and prescription coverage may be vital, vision and dental only make sense if you calculate savings with the expenses that you know you will incur.
I have been managing my health insurance relatively independently since adulthood, and have been completely responsible for managing it in all ways since 2005.
I know it can feel overwhelming and difficult to process – with a lot of acronyms and strange vocabulary and references to options that don’t quite make sense.
I hope I have made it a little easier for you to find the information you need and have helped you to face down the fear and anxiety that health insurance can evoke.
Don’t forget that open enrollment ends December 15th this year, so you only have another week to take advantage of it, if you haven’t already!
And if you haven’t looked into adjusting your plan and you are on Medicare, do yourself a favor and just run your medications through mymedicare.gov and make sure you are getting the best deal for yourself this year!