Don’t Have Health Insurance Right Now? Read This

Open enrollment typically runs from November to January of each year for health insurance coverage.

Here’s what you need to know:

Healthcare.gov: Your Resource for Private and Federal Health Insurance

• Healthcare.gov is a federal resource aimed at helping you find the best commercial (private) health insurance for you or federal health insurance like Medicaid or Children’s Health Insurance Program (CHIP) if you qualify.
• Healthcare.gov is a single database for healthcare coverage that operates for three dozen states.
• Fourteen states and Washington, D.C. run their own health insurance marketplaces. 
• If you are unsure which your state participates in, start at Healthcare.gov, which will direct you to your state’s marketplace if necessary.

Understanding Healthcare.gov plans and enrollment options

• A report from the Urban Institute showed that “almost half of uninsured adults familiar with state and federal health insurance marketplace plans had not sought information on them, most commonly because of cost concerns.

Qualifying life events that allow you to enroll anytime

• While open enrollment (usually in the fall) is a period in which anyone may sign up for health insurance, qualifying life events like job or life changes like moving, getting married, having a child, etc., allow you to sign up.
• If you qualify for Medicaid or CHIP, you can enroll at any time.

How to check your eligibility for Medicaid and CHIP

• By entering your information, you can determine which insurance options you qualify for.
• This includes private plans at different price points as well as government programs.
• You can also check your eligibility for Medicaid or the Children’s Health Insurance Program (CHIP) within your state.

Financial assistance for lowering health insurance costs

• If you are unemployed or facing financial burdens, you may qualify for financial assistance that will lower your insurance premium. 
• Through the Affordable Care Act (ACA), no one with a pre-existing condition may be turned away from healthcare coverage (being denied coverage because of health conditions like diabetes was fully legal before the ACA was implemented in 2010).
• But there are still many things to consider in your healthcare coverage as a person with diabetes. 

Choosing the right health insurance plan for diabetes care

• The cheapest health plan may not cover key diabetes costs, leading to high out-of-pocket expenses.
• Always check coverage details  to best understand what you will be expected to pay out of pocket per month.
• Read through our Health Insurance Guide for T1D to find out what to look for.

Understanding insurance coverage for diabetes technology

• If you use diabetes technology like an insulin pump or continuous glucose monitor (CGM), pay careful attention to the plan’s coverage for durable medical equipment (DME).
• While some insulin pump and CGM supplies have started going through the pharmacy benefit system, many still get routed through DME coverage, which is usually more expensive out of pocket.

Navigating prescription drug formularies and insulin coverage

• Each insurance plan comes with its own prescription drug formulary—the list of medications that are covered at various percentages under your health insurance.
• If you use a short-acting insulin like Humalog, an insurance plan may not cover Humalog (made by Ely Lilly) but instead cover the short-acting insulin Novolog (made by Novo Nordisk).
  • This is due to private business deals made between insurance companies, insulin manufacturers, and pharmacy benefit managers (PBMs), and can interrupt your ability to get the medication your body is used to.
• If you encounter this problem, work with your doctor to determine how to most affordably and effectively get the type of insulin you need.
  • They may be able to help you switch to the less expensive version of the same medication or help write a Letter of Medical Necessity so you can get your current insulin type.
• This formulary issue is also why you may notice the cost of your insulin changing, sometimes from an amount like $500 a month one year to $35 a month in another.
  • This has nothing to do with federal drug pricing policy and everything to do with private business deals between companies.

Overcoming challenges in the U.S. healthcare system

Becoming fully comfortable with navigating health insurance takes a lot of time and effort. It does not come naturally, and even those who are very well versed in health insurance coverage hit walls within America’s unnecessarily complex healthcare system.

Editor’s Note: The US Healthcare System is complex and confusing. For a variety of resources to help you navigate insurance coverage, check out our All About Insurance page.

Need help specifically with insulin? People who take insulin require consistently affordable and predictable sources of insulin at all times. If you or a loved one are struggling to afford or access insulin, visit GetInsulin.org.

Lean on our Health Insurance Guide, utilize our US Healthcare System Glossary and check out our Health Insurance Hurdles 101.