Health insurance is a large and complicated issue in the US. I want to talk about the practical considerations of 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?
The window for insurance open enrollment varies by the organization running it, but generally begins in October and ends in December. Medicare’s Open Enrollment period is October 15-December 7 every year, and the Affordable Care Act open enrollment period is November 1-January 15(select plan by December 15th for coverage to begin January 1, 2023). Some states have expanded their open enrollment period beyond these limits, but for all states, this is the minimum.
Most private insurers also have an open enrollment period at or around the same time – with most insurance plans selected going into effect on January 1. The details are normally determined and shared by your(or spouse/parent)’s employer(s).
Medicaid is sometimes an exception. If you are on Medicaid, check your state’s open enrollment period. Check here to see if your state currently has Medicaid expansion. In the states where coverage is expanded, your qualification is entirely income-based, but in states without Medicaid expansion, there are likely to be additional hurdles.
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. The only exception is that if you select a Medicare Advantage plan, you may change it once between January and March, either to a different Medicare Advantage plan, or to Original Medicare(and select your appropriate part D plan). This change can only be made once, so it’s very important that you feel confident in your selection.
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, whether Medicare or Medicaid, until the next open enrollment period.
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). Collecting SSI means that by definition you are Medicaid eligible.
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 vary 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.
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. Health Insurance coverage is essential for a disability, and quality coverage is often more expensive and more difficult to find.
Insurance through an employer
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 from, 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 in or near the low hundreds).
You do need to call your insurance and do paperwork associated with using COBRA – usually, that information is included in the 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. Because it is associated with separation from the employer, you now are shouldering 100% of the cost of the health insurance, whereas previously you and your employer were actually sharing the cost, even if you were unaware of this.
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 include a new job with new insurance, Medicare, Medicaid, or coverage through the ACA(or TRI-Care if you have a military history and are eligible).
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.
Insurance without an employer
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. In many cases, they offer income-based tax credits and other incentives to help you afford your plan.
If you are unemployed and have a disability, or are low-income in a state with an expanded Medicaid program, you may be eligible for Medicaid coverage. The ACA Marketplace can help you evaluate those options as well in many cases.
Medicaid is an insurance safety net for low-income individuals, especially children(CHIP is the name of the children’s program), pregnant women, and people with disabilities.
Getting onto Medicare takes a lot of time. It can take years to be awarded Social Security Disability Insurance(SSDI), and Medicare doesn’t start until 24 months after the official onset of disability.
With how slow the disability application process is currently running, many people find that their coverage starts once they receive their acceptance notification.
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.
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. Many charity care programs can also assist you in applying for Medicaid if you have used their services, since Medicaid will provide back pay to cover the previous three months of medical expenses.
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 $100-300, with more detailed X-rays required every 5 years or so), 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 an (often 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. This becomes more important as you get older and the risk of cataracts and other vision issues becomes greater.
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 $50-200 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. This is a risk I have chosen to take, and it’s a cost-saving measure worth considering if you have a history of minimal issues on these fronts.
However, if you have not regularly seen a dentist and you have the opportunity to get dental coverage, it may be worth investing in that coverage at least the first year it’s available, so you can get the more expensive testing and procedures completed while covered.
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 food bank 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/
I do *not* recommend using free services affiliated with any part of the health insurance network. Many pharmacies, for example, may mention a free program to help you select your Medicare Part D plan.
Their focus will be on keeping you within a particular network, and they may have additional agendas as well. I know it was one of those programs that tricked me into a Medicare Advantage Plan, and I’m far from the only person with a dubious experience with these groups.
If you have employer-based insurance, some employers may also offer some form of healthcare plan selection training or supports – check in with your human resources department.
I can also help, if you need it!
I am also now offering a coaching program designed to help people select their best health insurance option.
While I can help with selecting a Medicare or Medicaid plan, I think my program will best serve somebody who needs to decide between multiple disparate options, such as whether to use COBRA, the ACA Marketplace, or Medicare.
My goal with this service is to help people who are overwhelmed by their options and really need some guidance to understand the advantages and disadvantages of each choice.
Also, if you are very uncomfortable with the responsibility involved and want somebody to help you talk through your options, even if they are more limited, I’m very happy to be your sounding board and support you through your process.
It can feel very overwhelming to select a plan, especially when you are not used to doing so. I want to help you get past the overwhelm and find the option that best fits your needs, however small or large the differences between plans and however complex or simple your needs or limitations may be.
This year, I’m also offering a virtual masterclass to provide more affordable guidance on the matter.
I am not connected with any insurance plan, so in that sense, I don’t have a dog in the game.
The worst decision is no decision
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!
All other options are smaller risks, but that doesn’t mean they are unimportant.
You will 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.
Also, it’s important to recognize that the upfront cost(the premium) isn’t the entire cost. The only thing worse than not having reasonable insurance coverage is not using the insurance that you’re already paying for.
You deserve to find a plan that will help you live the best life you can, and to use it!
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 the fear and anxiety that health insurance can evoke.
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!