Are You Thinking of Changing Insurance During Open Enrollment?
Having a chronic condition means finding a plan that benefits you the most.
It’s that time of year again! Open enrollment, when you may be thinking about switching your insurance to accommodate your medical needs better, especially if you’re hugely dissatisfied with your current insurance plan.
Finding the best medical insurance plan during open enrollment can be challenging and overwhelming, especially for someone with a chronic illness like lipedema. I get asked a lot of questions about this, so I wanted to give some general practical advice—with the understanding that we all have specific medical needs.
You may think, “I have no choice because my employer only offers one plan.” However, even with employer-sponsored insurance (65% of commercial plans are self-funded), you might still have options within that plan. It's worth exploring your benefits to see what choices are available.
This post has some embedded resources and tidbits, so even though reading about insurance can be a boring process, please read to the end because you might find something beneficial!
Practical Advice for Choosing a Medical Insurance Plan for Someone with a Chronic Illness
When choosing your health insurance plan, it's essential to find one that truly fits your individual needs, especially if you're managing a chronic condition like lipedema. Making sure your plan offers the right coverage can help you access the care and treatments you need to maintain your health and well-being.
Here are some practical tips I can offer to help you pick the plan that best meets your needs.
Which Plan Type is Right for You?
I'll list four major plan types here. Within these plans are multiple variations, which I’ll explain in a minute:
PPO (Preferred Provider Organization): This plan provides more flexibility with out-of-network providers but at a higher premium. This type of plan is best if you’re anticipating needing liposuction surgery within the next year.
HMO (Health Maintenance Organization): This plan has lower premiums, but restricts you to only using their in-network providers. You also need a referral to see a specialist. This is the worst plan if you anticipate needing liposuction surgery within the next year, because most HMOs do not cover or recognize liposuction surgery as medically necessary for lipedema, they do not have in-network surgeons, and they do not allow going out of their network for care.
EPO (Exclusive Provider Organization): Like an HMO but without the need for referrals, yet still requires in-network providers. There’s typically no out-of-network coverage for this type of plan.
My insurance plan is set-up this way, although they call themselves a PPO, I have 0% coverage if I go out-of-network. However, I was able to get coverage for my out-of-network surgeon when I petitioned to be covered as in-network. Confusing as hell? Yep.
HDHP (High-Deductible Health Plan): Lower premiums but higher deductibles; pair with a Health Savings Account (HSA) for managing high out-of-pocket expenses. These plans can cost a lot of money. Plus, you will still get the choice of a PPO or HMO plan within the HDHP, so pay attention to what type of plan you’re being sold.
Compare Total Costs, Not Just Premiums
Premiums are the monthly payments, but you should also consider:
Deductibles: How much you pay before insurance kicks in. HDHP plans have high deductibles into the thousands of dollars that you need to pay before your insurance starts covering your medical bills.
Co-payments and co-insurance: The share of costs after your deductible is met.
Out-of-pocket maximums (OOP max): The most you’ll have to pay in a year before your insurance covers 100% of expenses. This is especially important for those with chronic conditions, as you may hit this maximum. Also, many expenses, including copayments, may not count toward your deductible.
The Four Metal Tiers of Health Insurance
Within the insurance structures, they are often categorized into four metal tiers: Bronze, Silver, Gold, and Platinum. These tiers represent how you and your insurance company split the costs of your healthcare. Here's a GENERAL breakdown of each:
Bronze Plan:
Lower premiums, but higher out-of-pocket costs when you need care.
Bronze plans usually have the lowest monthly premiums but the highest costs when you get care. They can be a good choice if you usually use few medical services and mostly want protection from very high costs if you get seriously sick or injured.
Silver Plan:
Moderate premiums with a balance between costs and coverage.
This plan often qualifies for cost-sharing reductions, which can lower your out-of-pocket costs if you have a lower income. Silver plans are popular because they offer a good middle ground.
Gold Plan:
Higher premiums, but lower out-of-pocket costs when you receive care.
Ideal for people who expect to need frequent medical care or would rather pay more up front and know that you’ll pay less when you get care.
Platinum Plan:
Highest premiums, but very low out-of-pocket costs.
This plan is best if you need a lot of care and are willing to pay more upfront in premiums to minimize costs later.
The key difference between these plans is how much you pay monthly versus how much you pay when you actually need healthcare. For someone managing a chronic condition like lipedema, Silver or Gold plans may offer a more balanced or comprehensive level of coverage for frequent treatments or doctor visits.
Check Coverage for Chronic Care
It pays to do a little extra diligence for your specific medical needs. Here are some extra steps!
List your current treatments: Consider regular doctor visits, prescription medications, therapies, and potential surgeries. Understand what services and specialists you'll need in the coming year.
Ensure treatments and specialists are covered: Some plans have exclusions or restrictions that may affect access to the care you need.
Look for coverage for specialized treatments: For lipedema, this might include lymphatic therapy, compression garments, or specialized surgeries.
Check drug formularies: Make sure your prescription medications are covered and compare how different plans categorize them in terms of cost.
Factor in the plan’s flexibility: Chronic conditions may require additional treatments, so choose a plan that allows flexibility for new or evolving needs.
Review Provider Networks
In-network providers: Confirm that your primary care doctor, specialists, and preferred hospitals are in-network. If they aren’t, you’ll have to switch providers or pay more out-of-pocket. Fear of losing access to current providers is one of the biggest reasons why people don’t switch their health insurance.
Rural Living and getting coverage: Living in a rural area, sometimes an insurance plan has NO contracts with the community providers. I have dealt with this many times on behalf of my hospital patients when trying to discharge them home and get them set up with home health or skilled rehab. If you live in a rural area, make sure the plan you’re choosing actually has contracted providers in your area. Otherwise, you’ll always be traveling to the nearest big city for care. And if you’re housebound, you may not be able to get care at all. This is especially important for home health care.
Telemedicine
If there’s one good thing that came out of COVID, it’s coverage for telemedicine. Most plans now cover telemedicine, but some don’t. Double-check to ensure your plan has this benefit. As someone with a chronic illness, I can’t express enough how convenient it is to have this option now.
Chronic Care and Disease Management Programs
Many insurance plans also offer chronic care management programs or disease management services. Traditional “Disease Management” in insurance terms refers only to cardiac, lung, and diabetes conditions.
However, most plans also offer chronic pain management programs in one form or another, which many lipedema women usually participate in for their care. These programs may include referrals to pain management clinics, health coaches, personalized care plans, or discounts for services and products related to your chronic condition. The best way to find out if you have access to one of these programs is to call the insurance plan or look at their website to see what they offer.
Consider Financial Assistance
If purchasing a plan through the Marketplace, you may qualify for subsidies to reduce premium costs. Look into Medicaid or Medicare options to see if you’re eligible, especially if your chronic condition qualifies you for additional assistance. Even if you know you don’t qualify, you never know for sure until you ask.
Talk to Your Providers
Ask your doctors which plans they recommend for your condition. They may have insights into which insurers are better at approving the treatments and medications you need.
Prior Authorization
Some treatments for chronic conditions may require approval before insurance will cover them. Medicare Advantage Plans all require prior authorizations, while Traditional or Original Medicare (Medicare A&B) does not.
All of the commercial plans require prior authorization. Be leery if your insurance plan tells you over the phone that they don’t require prior authorization. If your plan tells you this, get it in writing or through one of their medical policies (because they lie, unfortunately).
Out-of-network coverage
First, find out if you have out-of-network coverage. Some plans don’t! Mine doesn’t, and it’s very frustrating, but still workable.
If you travel or need a specialist out of network, understand how those visits will be covered and what you’ll pay out of pocket.
Also, if you live in a rural area, your network options might be very limited under certain insurances. Whatever you anticipate you’ll need in care, find out if the insurance covers that care in your community.
Use Available Resources
Healthcare.gov offers comparison tools to evaluate commercial (Marketplace) insurance plans. Open enrollment is November 1st!
Medicaid.gov is for low-income people, no matter the age. If you think you’re on the edge of coverage, ask for a Medicaid screen, as eligibility requirements vary by state and depend on factors like income level, family size, age, pregnancy status, and disability. It takes nothing but your time to find out, and you might be surprised that you qualify, which will save you a lot of money.
If you’re under Medicare and considered low-income, you may also qualify for Medicaid. Medicaid is considered secondary insurance and covers all expenses not covered by Medicare, including Medicare Advantage plans.
Medicare.gov enrollment opens October 15th! If you are satisfied with your current plan (including traditional Medicare) then your coverage will automatically renew for the following year unless you take action to change it.
If you have a Medicare Advantage plan and you want to change to Traditional Medicare A&B, do know that you may not be approved for secondary coverage (Medigap) and will be responsible for the 20% coinsurance.
Insurekidsnow.gov Millions of children and teens qualify for free or low-cost health and dental coverage through Medicaid & the Children's Health Insurance Program (CHIP). Children may be covered even if the parents are not.
Many states have health insurance assistance programs that provide guidance on selecting the right plan, especially for those with chronic conditions.
I know this is a lot! But working on the front side and doing your due diligence to get the best coverage will save you a lot of money.
Take care,
Michelle