Depending on your employment status, household size, and income, there are several types of insurance that you can qualify for. The four primary types of insurance are employer-based plans, plans on the Health Insurance Marketplace (also known as the Health Insurance Exchange), private plans (also known as off-exchange plans), and public insurance such as Medicare and Medicaid. Compass can help you understand what options are available for your circumstances and walk you through a side-by-side comparison of options.
You can select or make changes to your health insurance coverage during annual open enrollment. Coverage begins at a specified date after open enrollment and usually applies for a full year.
Employer-Based (Group) Plans
In the United States, most people have health insurance coverage through their own or a family member's employer. Employer-based health insurance, also called a group plan, is selected and purchased by an employer and offered to eligible employees and their dependents. Any businesses with 50 or more full-time employees is required to provide health insurance to their employees. Your employer will typically share the cost of your premium with you. Some employers may offer insurance through a labor or trade union.
There are two types of employer-based coverage: fully funded group plans and self-funded group plans.
Fully funded group plans: The employer purchases coverage from an insurance company and the insurance company processes and pays health care provider claims.
Self-funded group plans: The employer sometimes assumes the role of the insurance company, and processes and pays health care provider claims. However, in some cases, there may be a third-party administrator that assists with health insurance claims. For self-funded plans, it is often up to the employer to decide whether to cover a service. In most cases, appeals are made directly to the employer's human resources (HR) department.
The Consolidated Omnibus Budget Reconciliation Act (COBRA) is a form of employer-based coverage that gives employees and their families the option to extend their insurance if they lose job-based health coverage, such as by leaving their job or getting laid off. An employer is required to offer COBRA if it has 20 or more employees on more than 50 percent of its typical business days. Most qualified individuals are required to pay the full cost (which cannot exceed 102 percent of the premium, or the full cost of the coverage plus a two percent administration charge) of the plan. Because employers typically cover part of the premium while the employee is working, the cost of continuing coverage through COBRA can be significantly greater. COBRA coverage can continue for up to 18 months.
Once you opt into COBRA, you cannot drop it and switch to a Marketplace plan until the following year or until the open enrollment period, as voluntary loss of coverage is not considered to be a qualifying life event for the special enrollment period. You must have a qualifying life event or other unusual circumstance to buy a plan outside of the open enrollment period.
Those who do not take COBRA coverage can enroll in a Marketplace plan instead but will typically need to decide within 60 days of the loss of job-based coverage. The choice between COBRA and a Marketplace plan largely depends on your individual circumstances.
Health Insurance Marketplace Plans
The Health Insurance Marketplace, also known as the Health Insurance Exchange, provides people a way to buy a plan if they do not have access to group-based employer plans or do not qualify for Medicare or Medicaid. To access your state's Marketplace, visit healthcare.gov.
Typically, Marketplace insurance plans are grouped by levels of coverage named after different types of metals:
Bronze plans offer the least coverage but also have the least expensive monthly premiums. On average, you will pay 40 percent of your health care costs with a bronze plan.
Silver plans will usually require you to pay 30 percent of your health care costs.
Gold plans typically require you to pay 20 percent of your health care costs.
Platinum plans offer the most coverage but also have the most expensive monthly premiums. On average, you will pay 10 percent of your health care costs with platinum plans.
You can buy a new plan or make changes to an existing Marketplace plan during the annual open enrollment period. You may qualify for a special enrollment period if you have a qualifying life event or other unusual circumstance.
Based on your household size or income, you may be eligible for a subsidy in the form of a tax credit on your monthly premiums. You can qualify for a premium tax credit if your household income range is between 100 percent and 400 percent of the Federal Poverty Level (FPL). For more information on eligibility, visit the Saving Money on Health Insurance section on healthcare.gov.
Marketplace plans also offer access to cost-sharing reduction plans, which are specially designed silver plans featuring lower copays and deductibles. These plans are only available to people with incomes between 100 percent and 250 percent of the FPL. Individuals who fall within this category can take advantage of the premium subsidy at the same time.
Private Insurance Plan
Private or off-exchange insurance is provided by nongovernmental sources, such as private insurance companies. Individuals can purchase these plans through a broker or directly from an insurance company outside the marketplace. These plans vary greatly in what services are covered, premiums, and other out-of-pocket expenses. You can buy a new plan or make changes to an existing private plan during the annual open enrollment period. You must have a qualifying life event or other unusual circumstance to buy a plan outside of the open enrollment period.
Public Insurance Programs
Public health insurance programs are government-funded and provide health care assistance to qualifying individuals and their families. These programs include:
Many states also have CF-specific programs such as programs for children with special health care needs (sometimes called CSHCN programs). In most states, families that do not qualify for Medicaid may be eligible for this program, although some states require enrollment in Medicaid to qualify. Some states may also offer this program to adults who have a qualifying diagnosis.
Primary Versus Secondary Insurance
Many people with cystic fibrosis report having more than one form of health insurance coverage. In these cases, you will have both a primary and a secondary insurance provider and your benefits must be coordinated to ensure you receive maximum coverage.
Your primary health insurance plan is the first to pay for services or treatments you receive. If the primary plan does not cover a service or treatment completely or at all, then your secondary health plan or program may cover it. It is important to notify both plans, so that coordination of benefit can be set up correctly. If the claim gets billed in an incorrect order, it may result in you receiving a bill in the amount higher than your actual responsibility.