Health Insurance Open Enrollment: How to Choose a Plan with Type 1 Diabetes

Is It Open Enrollment for Everyone?

Open enrollment is a set period when people can sign up for or change certain health insurance plans. Your dates depend on where you get coverage.

• People buying their own insurance through the Affordable Care Act (ACA) Marketplace have an annual enrollment period. Dates can differ between the federal Marketplace and state-run Marketplaces, and they can change from year to year. Check HealthCare.gov or your state Marketplace for the current deadline.
• Employers also set enrollment periods for their health plans, usually once a year. Your human resources department can tell you when to make a choice and when the new coverage begins.
• Medicare has a separate annual open enrollment period, from Oct. 15 through Dec. 7. During that time, people can review and make certain changes to their Medicare Advantage or prescription drug coverage. This is different from the enrollment period for someone first becoming eligible for Medicare.
• Medicaid and the Children's Health Insurance Program (CHIP) do not have annual open enrollment windows. Eligible people can apply at any time.
• A Special Enrollment Period (SEP) lets some people enroll in Marketplace coverage outside its regular window after a qualifying life change, such as losing other coverage, getting married, having a baby or moving. Deadlines depend on the situation.

If you already have coverage, do not assume it will work the same way next year. Read the renewal materials and compare your options before the deadline.

Look Beyond the Monthly Premium

The premium is what you pay each month to keep your insurance. It is the easiest number to spot when shopping, but it does not show what a year of diabetes care will cost.

A deductible is what you pay for certain covered care before the plan begins paying its share. You may also owe a copay (a set dollar amount) or coinsurance (a percentage of a covered cost). The out-of-pocket maximum limits what you pay for covered, in-network care during a plan year. Premiums do not count toward that limit.

To compare plans, calculate 12 months of premiums. Then estimate your costs for insulin, sensors, pump supplies, visits, laboratory tests and other regular care. Ask whether prescriptions and supplies have copays before the deductible or whether you must meet the deductible first. HealthCare.gov provides tools to compare estimated yearly costs, but check the estimate against what you actually use.

A plan with a higher premium could cost less over the year if it covers your supplies at a lower price. A low-premium plan could still be the right choice. Compare the total cost alongside coverage for the people and products you depend on.

Check Whether You Qualify for Marketplace Savings

If you shop through an ACA Marketplace, complete the application to see whether you qualify for financial help. There are two kinds, and they work differently.

A premium tax credit lowers your monthly bill. It can be applied to a plan at any metal level, from Bronze through Platinum.

A cost-sharing reduction lowers what you pay when you actually use care, such as your deductible, copays and coinsurance. This one comes with a catch: it only applies if you choose a Silver plan. Pick Bronze or Gold instead, and you lose the cost-sharing reduction entirely, even if your income would have qualified you for it.

Some people qualify for both. If your application says you qualify for extra savings, compare Silver plans closely before choosing a different metal level based on its premium alone. A lower Bronze premium can be outweighed by the savings on deductibles and copays from Silver's cost-sharing reduction.

Marketplace plans are grouped into categories such as Bronze, Silver and Gold. Those categories describe how costs are generally shared. They do not tell you whether your insulin brand, CGM or endocrinologist is covered. You still need to check each plan's details.

Understand the Plan's Network and Rules

An HMO generally expects members to use in-network clinicians for routine care. Some HMOs require a referral to see a specialist. A PPO may offer more flexibility, including some out-of-network care, but out-of-network care can cost much more. The exact rules vary by plan.

If you are considering a high-deductible plan, find out what you will pay for prescriptions and supplies before meeting the deductible. Ask whether any medications have a lower cost from the start of coverage. Check whether the plan allows you to contribute to a health savings account (HSA), if that matters to your budget.

Do not rely on a familiar insurance company name. An endocrinologist may participate in one of its plans but not another. Confirm the exact plan name with both the insurer and your clinician's office. Do the same for your pharmacy, laboratory and diabetes supply company.

What ACA Coverage Means for Type 1 Diabetes

ACA Marketplace plans cannot reject you or charge you more because you live with type 1 diabetes (T1D). They must cover essential health benefits, including prescription drugs. But plans can differ in which drugs and devices they cover and what members pay for them.

Before you enroll, open the plan's Summary of Benefits and Coverage. It presents major benefits and costs in a standard format. Then review the drug formulary, which lists covered medications, and the documents that describe medical equipment coverage. You may need all three to understand how a plan handles insulin, a CGM and a pump.

If you are shopping outside an official Marketplace, ask what kind of policy is being sold. Confirm whether it follows ACA rules and covers pre-existing conditions, prescriptions and the supplies you use.

Six Questions to Ask about Diabetes Coverage

Make a list of your exact insulin names and formulations, devices, supplies, prescriptions and care team. Use that list to check each plan. These questions can help:

1. Is my insulin on the formulary? Ask what it will cost at your preferred pharmacy and whether quantity limits apply. If it is not listed, ask about the plan's exception process.
2. Are there prior authorization or step therapy requirements? These rules may require your prescriber to send information or have you try another covered product first.
3. How is my CGM covered? Ask whether you obtain it through a pharmacy or a durable medical equipment supplier. Check the specific sensors and other parts you use.
4. What will my pump and supplies cost? Ask separately about the pump, infusion sets, pods, cartridges and replacements. Coverage for the pump does not answer every supply question.
5. Are my clinicians and suppliers in network? Check your endocrinologist, primary care clinician, pharmacy, laboratory and equipment supplier.
6. Will I need new prescriptions or approvals? An authorization under your current plan may not carry over when you switch.

Check test strips, glucagon and routine laboratory work, too. When you call an insurer, use exact product names. Record the date, representative's name and a reference number. If an answer is unclear, ask where the policy explains the benefit in writing.

What Should People with Medicare Check?

If you have Medicare, review both medical and drug coverage. When comparing prescription drug plans, enter your insulin's exact name, then check its cost at the pharmacy you use. Review other prescriptions as well.

Insulin used with a pump covered under Medicare Part B's durable medical equipment (DME) benefit is generally handled through Part B rather than Part D. Ask how your pump, insulin and supplies are covered. Do not assume they all follow the same rules. Medicare limits what people pay for a month's supply of covered insulin, but you should still confirm that your particular products and suppliers meet the coverage requirements.

If you have Medicare Advantage, confirm that your clinicians, hospital and suppliers remain in the plan's network. For free, unbiased help comparing Medicare options, call 1-800-MEDICARE (1-800-633-4227) and ask how to reach a State Health Insurance Assistance Program counselor.

Can an FSA or HSA Help with Diabetes Costs?

A flexible spending account (FSA), often offered by an employer, lets you set aside pre-tax money for eligible health expenses. You generally choose an amount during your employer's enrollment period. Some plans allow changes after certain life events. You could lose unused funds at the end of your plan year, though some employers offer a limited carryover or grace period. Check your plan's rules before deciding how much to contribute.

An HSA is available to people who meet its eligibility rules and have qualifying coverage. Unused money stays in the account from year to year. Ask whether the health plan you are considering is HSA-eligible and whether another type of coverage affects your ability to contribute.

These accounts can help you budget for qualified expenses. First, make sure the insurance plan itself covers the care and products you need.

Prepare before Your Coverage Changes

A new insurance card doesn't guarantee an old prescription or device approval will work immediately.

Before your coverage begins, count how much insulin, how many sensors and how many pump supplies you have left. Check when you can refill them.

Ask your prescriber whether the new plan needs prescriptions, chart notes or prior authorizations. Find out which pharmacy and supplier to use. Keep records of problems you have had with alternative medications or devices in case your care team needs to request an exception.

If the plan denies coverage, ask for the denial reason in writing and find out how to appeal. Depending on the situation, you may be eligible for an internal appeal or an independent external review.

Your care team can help explain why a particular treatment is medically necessary.

If you are running low on insulin or risk missing doses, contact your diabetes care team right away for a safe plan. Ask about urgent authorization, a temporary fill or assistance while the insurance issue is resolved.

Where to Find Free Enrollment Help

• Marketplace: Search localhelp.healthcare.gov or call 1-800-318-2596 for trained navigators who can help you understand options and apply for coverage.
• Medicare: Call 1-800-MEDICARE for plan questions.
• Medicaid: Contact your state Medicaid agency to check eligibility and apply.
• Your clinic: A social worker or financial navigator may help you work through a coverage problem.
• Community health centers: Search findahealthcenter.hrsa.gov if you need care while sorting out a coverage question.

Start with one list: the insulin, devices, supplies, prescriptions and clinicians you rely on. Check each plan against it, then compare the estimated total cost for the year. That gives you a clearer way to choose coverage that fits your life with T1D.