Can someone chronically ill get insurance on marketplace

It’s that time of the year again: Open enrollment, the short period when you can select your health insurance for the coming year.

Whether you’re trying to select an Affordable Care Act (ACA) Marketplace plan or an employer-sponsored plan, you’ll have a variety of choices – which can make your choice complicated. In addition, if you are managing a chronic condition such as diabetes or asthma, it’s particularly important to find a plan that will meet your health care needs and your budget. Consider these tips for finding the right fit.

Look at all of the costs, not just the premium

• The premium is the amount you pay to be covered by an insurance plan. When it comes to total cost, however, the premium is just the beginning.
• If you’re shopping on the ACA exchange, check if you qualify for a subsidy – in the form of a tax credit – to lower your expenses. Subsidies are based on income, and more people than ever qualify due to the pandemic. In many cases, people pay little or no premium after their subsidy is applied.
• The deductible is the amount you’ll pay out of pocket before your insurance begins to cover its portion of the costs. In some plans, a single deductible applies to health care services and medicines. In other plans, you’ll have two deductibles: One for medical, one for pharmacy. Most plans – including all ACA plans – provide basic preventive care (such as annual check-ups) at no out-of-pocket cost to you, even before you meet your deductible.
• After you meet your deductible, you’ll be responsible for the coinsurance, which is a percentage of the total cost of your covered medical bills. For example, if your coinsurance is 20% and the covered charge totals $50, you’ll pay $10 and your insurance will pay $40. Alternatively, some benefits include a copay, which is a fixed dollar amount you pay for some medical treatments instead of a percentage of the doctor’s charges. For example, you might have a $30 copay for a visit to your primary care doctor.
• The out-of-pocket maximum is just that – the most you will pay for covered expenses during the year. It includes deductibles, copays, and coinsurance – everything but the premiums. If you reach the out-of-pocket maximum, the health plan will pay for 100% of covered medical and prescription costs for the rest of the year.

Pick the network that’s right for you

• Insurance plans build networks of doctors, specialists, pharmacies, and other medical care providers to serve their customers. Before you select a plan, you’ll want to evaluate the plan’s network to see which doctors are available to you “in network.” This may be especially important if you have a preferred specialist that you see for a chronic condition. Once enrolled, if you go out of network, you generally will need to pay a larger amount of your own money out of pocket. In some cases, your out-of-network care may not be covered – leaving you responsible for the entire cost.

Pick the type of insurance plan that’s right for you

• The types of health plan options include health maintenance organizations (HMOs), exclusive provider organizations (EPOs), point-of-service (POS) plans, and preferred provider organizations (PPOs). Some plans require you to have a primary care physician who will refer you to specialized care. Some offer out-of-network coverage at a higher price, while some do not cover it at all. Generally, more restrictive plans will cost you less in premiums. Think about how and where you access care to determine which plan types will work for you.

Consider your family’s needs and medical conditions

• Although the monthly premium may be higher, a plan with lower deductibles and lower coinsurance might be right for people with chronic conditions, who often require regular medication and frequent doctor appointments and are more likely to need to be hospitalized or undergo surgery.
• Check whether plans offer any added-value benefits specific to your conditions, such as caps on the amount you pay monthly for medications or supplies.
• Some insurers offer condition-specific plans that can help keep costs down. For example, Cigna offers plans for diabetes as part of its ACA offering. Patients pay little or nothing for select equipment and supplies, preventive care, common medications and the medical services they need to manage their conditions. As you shop, check for plans that offer additional value to you.
• To determine if a plan offers mental health coverage, look for “mental health,” “behavioral health,” or “substance abuse services” in the Summary of Benefits. This document explains which services are covered and how much they will cost. Also check the plan brochure for features that impact mental health care access or affordability. For example, Cigna Healthcare's individual and family plans offer a large network of in-person providers plus virtual access to more than 2,500 board-certified doctors and behavioral care providers through MDLIVE.
• If you and your spouse or partner each have access to employer plans, check to see which provides the most affordable premiums, lowest deductibles, and a network with your preferred doctors. Consider how much you would pay if you had lower or higher health care needs during the year and be sure to look at the premiums and deductibles when just the employee is covered vs. the entire family. You might decide that each of you should sign up with your own employer, or you might select one plan for your whole family.

Customers have until Jan. 15 to enroll in plans offered through the Affordable Care Act (ACA) Marketplace, but you should sign up by Dec. 15 to have coverage start on Jan. 1.

Affordable health insurance plans

For 2024, Cigna is offering a new Individual and Family Health Insurance Plan specifically designed for those with chronic conditions.