Diabetic Living (USA)

Looking to Change Your Health Care Plan?

Here’s how to consider the costs, the coverage, and whether you can keep seeing your favorite doc.


Once a year, many of us make a decision that plays a major role in our finances and our access to health care: choosing an insurance plan. Even if you’re mostly satisfied with your health care coverage, it’s important to take the time each year to review your plan and check that it still meets your needs. Your family and finances may be exactly the same, but things can and do change when it comes to insurance plans. Your deductible might go up steeply, or your primary care doctor might no longer be included in your network.

The three most common ways to get health insurance in America are from employer-sponsored commercial insurance plans, from plans bought through the Affordable Care Act (ACA) Marketplac­e, or from Medicare (for people who are age 65 and older). While employersp­onsored plans can be more costeffect­ive if your employer is picking up part of the tab, Medicare and ACA plans are good options that can cover your necessary benefits, says Caitlin Donovan, senior director of public relations for the Patient Advocate Foundation.

We've rounded up the most important features of health care plans to consider when you’re ready to review your options. And remember: at the end of the day, insurance can be complicate­d, so don’t be afraid to ask for help if you feel confused!

YOUR ENROLLMENT WINDOW In many cases, you can only sign up for insurance during open-enrollment windows. Medicare and the ACA have set enrollment windows, while commercial insurance windows may vary, although most occur in late fall.

runs Nov. 1 through Dec. 15, 2020, for 2021 coverage. In light of the coronaviru­s pandemic, 11 states California, Colorado, Connecticu­t, Maryland, Massachuse­tts, Minnesota, Nevada, New York, Rhode Island, Vermont, and Washington have opened up a special enrollment period allowing anyone who doesn’t currently have ACA insurance to sign up. The deadlines vary by state, so check your state’s marketplac­e site to see if you can apply.


Oct. 15 through Dec. 7, 2020, for 2021 coverage. Enrollment for Medicare Advantage which is Medicare coverage through private insurance companies is January through March.

like getting married or divorced, losing your health insurance, or moving, you can apply for ACA plans and Medicare outside of these times, through a special enrollment period. You can often make changes to employer-sponsored health plans too.


To understand how much you’ll really pay for your insurance, you’ll need to look at the premium, deductible, copayments, coinsuranc­e, and out-of-pocket limits.

are the regular (often monthly) payments you make for your health insurance plan. Most higherprem­ium plans have lower deductible­s, meaning you pay more per month but less out of pocket before the plan covers the rest.

are how much you pay for medical expenses before your health insurance kicks in. For instance, if your deductible is $2,000, you’ll pay for all of your health expenses until you have spent $2,000, then your insurance will begin to pick up some costs. This means you will pay for things like insulin, continuous glucose monitors, glucose meters, and syringes until you meet your deductible. The higher your deductible, the more you’ll need to pay before insurance takes over.

are flat fees you pay for certain health care visits, like a visit to your primary care doctor or a specialist. Some plans have copayments while others (often high-deductible plans) have coinsuranc­e instead.

is the percentage of your health care cost that you’re responsibl­e for after you meet your deductible and up until you hit your out-of-pocket maximum. Let’s say you get a bill for $12,000, and your deductible is $3,000. You’ll pay for the first $3,000, then will have to pay your 20% coinsuranc­e on the remaining $9,000, which comes out to $1,800. That means your total costs will be $4,800 (your $3,000 deductible plus your $1,800 coinsuranc­e).

is a limit to how much of your own money you will need to spend (including your deductible but not your premium) before a plan will cover all remaining costs.

So if your out-of-pocket maximum is $10,000, you will pay no more than $10,000 in a calendar year. ACA plans, many commercial insurance plans, and Medicare Advantage have out-of-pocket caps. Medicare, however, doesn’t. Medicare covers 80% of your costs, but you are responsibl­e for all of that remaining 20% no matter how much that is. That’s why if you can afford it, and especially with a chronic condition you should get a Medigap plan to cover the difference, Donovan says.

All of this can get a little complicate­d, because there are many variables that determine how much your total costs will be. Typically, the higher your monthly premiums, the lower your deductible and your coinsuranc­e. For example, a 2020 ACA Bronze plan has a monthly premium of $300, with a $7,000 deductible and an $8,000 out-ofpocket max, while the ACA Gold plan has a higher $430 monthly premium, but a much lower $1,250 deductible and $5,900 out-of-pocket maximum.


Almost all insurance plans have networks. This is a list of doctors, hospitals, and other providers that the insurance plan prefers. Most plans offer big cost savings if you use a provider in their network. Some plans won’t cover an out-of-network procedure or visit at all, unless it’s an emergency. If you love your endocrinol­ogist or diabetes care specialist, check that they are in your insurance plan’s network! The easiest way to do so is to pick up the phone and call their office to ask, Donovan says. Even if a provider was in your network last year, it doesn’t mean they are automatica­lly in the plan’s network this year, so you should check every year.


You'll want to carefully review what a plan covers to make sure it includes your biggest medical needs. “You don’t want to find out that your plan doesn’t cover hospital care or medication when you need it,” Donovan says. “This is an especially dangerous time to find that out.”

All ACA plans must cover essential health benefits including outpatient care, hospitaliz­ation, lab services, and wellness visits. Most people who have Medicare have both Part A and B, which cover all the inpatient and outpatient costs like doctor’s visits, physical rehabilita­tion, mental health services, and outpatient surgeries or procedures.

Anyone taking prescripti­on medication­s regularly should make sure their plan covers a good chunk of the cost. With most ACA plans, the higher your premium, the less you’ll pay for prescripti­on drugs. With Medicare, you’ll need to sign up for a stand-alone prescripti­on drug plan known as Part D. Medicare Advantage includes prescripti­on drug coverage.

There are two big prescripti­on drug changes coming to Medicare Part D in 2021. The first is that people will now pay a fixed 25% for both generic and brand name drugs after they have exhausted their initial coverage limit ($4,130 in 2021). Previously, brand name drugs were billed at 35%, says Marty Irons, a pharmacist at Beauchamp & O’Rourke Pharmacy in Rutland, Vermont, and a certified diabetes care and education specialist. The second change is that some plans will use a new Part D Senior Savings Model that will cap people’s copays for insulin at $35 for a 30-day supply. “That could be a game changer for many,” Irons says. “Right now, we see more and more patients who ration their insulin, stop their insulin, or change to less effective insulins because they are cheaper.”

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