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Diabetes and Insurance: Shopping the Marketplace

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The next Affordable Care Act (ACA) open enrollment period starts midway through October and ends December 7th for coverage that starts the following year. During this period, you can buy insurance through the Health Insurance Marketplace (Marketplace) in your state.

Anyone purchasing health coverage on their own can use the Marketplace. People who meet specific income criteria, and do not have affordable employment-based insurance available, may qualify for assistance paying their premiums and other costs—but only for plans purchased through the Marketplace.

Since January, 2014

Starting in 2014, new health insurance plans can no longer deny coverage, charge higher premiums, or refuse to cover treatment because you or a family member has diabetes. This is true for plans offered within or outside the Marketplace.

However, plans offered within the Marketplace, and job-based plans, have to meet specific benefit, cost, and consumer protection requirements. Healthcare plans purchased directly from an insurance company might not meet these same standards.

Most individuals in the U.S. are now required to have health insurance and will face a tax penalty the following year if:

  1. They do not have health insurance and did not qualify for an exemption.
  2. Have a policy that does not meet the minimum standard requirements set forth in the ACA.

Marketplace applications can be submitted online, in person, or over the phone during open enrollment. There is supposed to be free individual assistance available for selecting a suitable plan and enrolling—simply by contacting your state Marketplace. If you need help contacting your state Marketplace call 1-800-318-2596 anytime.

ACA Essential Benefits

Health coverage purchased through the Marketplace is required to cover the following “essential health benefits.”

      Physician office visits, ER services, and hospitalization.

 

      Pregnancy and newborn care.

 

      Substance use and mental health disorder services.

 

      Prescription drugs and laboratory services.

 

      Chronic disease management.

 

      Preventive services, such as screenings.

 

      Children’s health services (including oral/vision care).

 

    Rehabilitation devices and services.

A Marketplace insurance plan cannot limit the dollar amount spent on these “essential health benefits” in a given year or during your entire time of enrollment. In addition, these plans must limit subscribers’ out-of-pocket expenditures and provide specified preventive services (e.g., blood pressure, depression screenings) without charge.

Insurance plans can only charge higher premiums for tobacco use, age, geography, and family size. They can limit the number of doctor visits, number of prescription medications, and/or hospitalization days.

All health plans must provide policy holders an SBC and a glossary of standard health insurance terms. An SBC is a short, plain-language Summary of Benefits and Coverage. Each plan in the Marketplace has a link to its SBC, so shoppers can compare plans.

Diabetes Coverage

If you are satisfied that your current insurance meets your diabetes and other healthcare needs there is no need to change policies; just make sure your plan meets the minimum ACA policy requirements to avoid a tax penalty.

Those of you shopping for coverage, be sure to ask whether the plan you are considering covers diabetes services, supplies, the prescriptions you need, and what the costs are. The amount you are expected to pay for these services can vary between plans.

To see if you qualify for a special enrollment period or Medicaid/CHIP, or for more information about the Health Insurance Marketplace, go to healthcare.gov.

Source: American Diabetes Association

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