Depending on your employment status, household size, and income, there are several different types of insurance that you can purchase or qualify for. The three primary types of insurance are private (also known as commercial) or employer-based, the Health
Insurance Marketplace and public insurance such as
Commercial, Private, or Employer-Based Insurance Plans
Private or commercial insurance is health coverage purchased directly from a health insurance company either with a group, such as an employer, labor union, university, or individually. Any business with 50 or more full-time-equivalent employees is required
to provide health insurance through a private employer-based plan.
These plans vary greatly in what health services are covered and how much each individual must pay for
premiums and other out-of-pocket expenses. Employees are often able to add their spouse or dependents to a group insurance plan for a higher monthly premium cost. If you wish
to change your plan or enroll in a new one, you can do so during the
open enrollment period, which may vary depending on the type of insurance you have.
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 in the event that they lose job-based health coverage. An employer is required
to offer COBRA if it has 20 or more employees on more than 50 percent of its typical business days. For COBRA, 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 2 percent administration charge) of the plan. 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.
Those who decide not to take COBRA coverage can enroll in a Marketplace plan instead but will typically be asked to make a decision fairly quickly once the loss of job-based coverage occurs. The choice between COBRA and a Marketplace plan largely depends
on your individual circumstances and varies on a case-by-case basis, but a Cystic Fibrosis Foundation
Compass case manager can work with you one-on-one to weigh the pros and cons of each option and help you decide on the right plan.
Group Insurance Plans
The majority of individuals in the United States have group health coverage through their own or a family member's employer. There are two types of employer-sponsored coverage: fully-funded group plans and self-funded group plans.
In a fully-funded group plan, the employer purchases coverage from an insurance company and the insurance company processes and pays health care provider
In a self-funded group plan, 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 or not to cover a service. In most cases,
appeals are made directly to the employer's human resources (HR) department.
Individual health insurance plans are another type of private insurance purchased by individuals or families directly from an insurance company or through the Health Insurance Marketplace.
The Health Insurance Marketplace, also known as the Health Insurance Exchange, was created as a result of the Affordable Care Act (ACA) to help U.S. residents pay for health care. For those who do not have access to group-based employer plans or do not
Medicaid, the Marketplace provides a way to go online and purchase a plan in order to ensure that they have adequate
Although some states are in the Federally-Facilitated Exchange, others have their own state-based Exchanges that function very differently. This means that the way a Marketplace plan works
varies by state. To access the Marketplace for the state in which you live, visit
Typically, Marketplace insurance plans are grouped by levels of coverage classified by different types of metals:
Bronze: Bronze plans offer the least amount of coverage but are also the least expensive in terms of monthly premiums. On average, with a bronze plan, you will pay 40 percent of your health care costs.
Silver: With a silver plan, you will usually pay 30 percent of your health care costs.
Gold: Gold plans typically require you to pay 20 percent of your health care costs.
Platinum: Platinum plans offer the most amount of coverage but are also the most expensive in terms of monthly premiums. On average, with a platinum plan, you will pay 10 percent of your health care costs.
As with Medicare, you also need to sign up for a Marketplace plan during that year's open enrollment period, which in 2017 is from November 1 through December 15. However, those who qualify for
special enrollment periods due to
a qualifying life event or other unusual circumstance can still buy a Marketplace plan outside of the open enrollment period. For a list of qualifying life events, visit healthcare.gov.
If you do decide to purchase a plan from the Health Insurance Marketplace, you may be eligible to receive financial assistance from the federal government in the form of a Marketplace subsidy. There are two main types of Marketplace subsidies -- a premium
tax credit and a cost-sharing reduction -- which are available based on your household size and income.
If you live in a state that has
expanded their Medicaid eligibility under the Affordable Care Act and your income falls between 138 percent and 400 percent of the federal poverty level (FPL), you can qualify for a premium tax credit to be put toward your tax return the following
year or used up front to have a lower monthly premium. If you live in a state that has not expanded their Medicaid eligibility, the income range to qualify for subsidies is between 100 percent and 400 percent.
Although most people will choose to pay less for coverage each month, it may be a good idea for individuals whose incomes fluctuate a lot, for example, to wait until they do their taxes to use their subsidy.
* For Alaska and Hawaii, see
the U.S. Federal Poverty Guidelines, U.S. Department of Health & Human Services.
Plans purchased on the Health Insurance Marketplace also offer a subsidy called a cost-sharing reduction, which is available to people with incomes between 100 percent and 250 percent of the FPL. Individuals who fall within this category can not only
take advantage of the premium subsidy but also choose between special, limited income-based, silver plans featuring lowered
For this reason, people who meet these income requirements should be sure to look into silver Marketplace plans when considering coverage as opposed to automatically defaulting to the cheapest option.
Considering a Plan
When it comes to deciding if a Marketplace plan is right for you, you should start by answering a few key questions. First of all, you need to know if you are eligible for subsidies for your plan. Second, it is important to make sure that your doctor
and pharmacy are
in-network before selecting a plan. Although lower health insurance costs up front may seem appealing, making sure that the plan you select effectively covers
specialty care and treatments from your CF care center is extremely important and can ultimately help you save in the long run.
Deciding if a Marketplace plan is right for you depends largely on you and your specific health care needs,
treatment plan, so it is important to consider different factors before making a decision. A CF Foundation
Compass case manager can help you weigh these factors and calculate each plan's overall expenses to determine the best type of insurance for you.
Benefit Assessment Checklist for more information on choosing the right plan.
Government health care programs are government-funded and provide health care assistance to qualifying individuals and their families. The largest of these programs are
Medicaid, but government health care programs also include the Veterans Health Administration (VHA), the Children's Health Insurance Program (CHIP), the Department of Defense
TRICARE and TRICARE for Life programs (DOD TRICARE), and the Indian Health Service (IHS).
In addition to these federal programs, many states offer assistance programs for managing your CF care. State-level programs for children with special health care needs (sometimes called CSHCN programs) provide assistance for coverage of care for certain
chronic conditions, such as CF. 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.
To learn more about the government programs available in your state and to find out if you are eligible for assistance, contact your CF care center or CF Foundation Compass.
Primary vs. Secondary Insurance
Today, a quarter of 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.
Your primary health insurance plan is the first to pay for services or treatments you receive from a health care provider. However, if the primary plan does not cover a service or treatment completely or at all, then your secondary health plan or program
may cover that care. For help coordinating your benefits or to clarify if a plan is considered primary or secondary, you can always review your insurance plan, speak with a
member of your CF care team or call CF Foundation Compass.
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