PART 3—Breaking Down the 3 M’s of Health Insurance Options
This article is part of our new Summer Series lineup that will take you through the ins and outs of some common government benefits programs that many people utilize post-brain injury, including SSDI, SSI, Medicaid, Medicare, and more!
Note: The information presented in this article is not intended to be comprehensive and is not official legal advice. Its purpose is to provide you with insights and direction to help you access the resources most appropriate to your individual situation. You should consult a professional regarding documentation, additional questions, etc.
At the onset of a brain injury, survivors can experience loss of work, income, and even family support. If your health insurance was tied to your employment, it can also be a scary time if you now need new health insurance coverage.
In this installment of our summer series, we will get you up to speed on the big three government health care options: Medicaid, Medicare, and the Marketplace (a.k.a. “Obamacare” and The Affordable Care Act).
Applying for each of these programs can be a challenging process. Fortunately, you don’t have to do it alone. There are services that can help you complete the applications, answer your questions, and provide further information and resources as needed. It is recommended that you utilize these resources as able.
MARKETPLACE HEALTH INSURANCE (OBAMACARE/THE AFFORDABLE CARE ACT)
If your income level is too high for AHCCCS (Medicaid), or insurance isn’t provided through your employer, the Marketplace is another way you can obtain health insurance. It’s also an appropriate option for those who have applied for Social Security Disability Income (SSDI) and must wait the 24-month period before their Medicare benefits take effect.
1. WHAT IS MARKETPLACE HEALTH INSURANCE?
Health Insurance Marketplaces (also known as Exchanges) are organizations set up to create more organized and competitive markets for buying health insurance. They offer a choice of different health plans, certify plans that participate, and provide information and in-person assistance to help you apply for coverage.
Through the Marketplace, individuals and families can shop for coverage if they need to buy health insurance on their own. Depending on the plan you choose, there are associated costs such as premiums, co-pays, deductibles, and other out-of-pocket expenses.
However, income-based cost-sharing and premium subsidies are available to lower costs and make coverage more affordable.
2. WHO CAN BUY COVERAGE IN THE MARKETPLACE?
To be eligible you must:
- Live in the same state as your marketplace
- Be a citizen of the U.S. or be lawfully present in the U.S.
- Not currently be incarcerated
It’s important to note that not everybody who is eligible to purchase coverage in the Marketplace will be eligible for subsidies. To learn more about qualifying for subsidies (also called premium tax credits), check out this HealthCare.gov quick guide.
3. WHEN DOES ENROLLMENT TAKE PLACE?
In general, you can only enroll in non-group health plan coverage during the annual Open Enrollment period. For 2021, the Open Enrollment period is November 1, 2020 through December 15, 2020 (in most states).
Once the Open Enrollment period ends, you will not be able to enroll in Marketplace health plans until the next Open Enrollment period. However, if you experience certain changes in circumstances during the year, such as marriage, divorce, birth, employment change, etc., you may qualify for a Special Enrollment, wherein you’ll have a 60-day window to enroll in a health plan.
4. WHAT ARE THE INCOME GUIDELINES?
Marketplace health insurance is based on the upcoming year’s income (NOT previous years). In states that have expanded Medicaid coverage, your household income must be below 138% of the federal poverty level to qualify.
In all states, your household income must be between 100% and 400% of the federal poverty level to qualify for a premium tax credit that can lower your insurance costs.
5. HOW DO I APPLY?
You can apply over the phone 24 hours a day, seven days a week, by calling 1-800-318-2596
Complete the application at HealthCare.gov
There are also Assisters who are trained and certified to help you apply and enroll in a health plan with savings. They can even assist you with applying for the Children’s Health Insurance Program (CHIP), if needed.
6. HEALTH INSURANCE PLAN CONSIDERATIONS
There are four “metal” categories of health insurance plans: Bronze, Silver, Gold, and Platinum. These categories show how you and your plan share costs and have nothing to do with the quality of care.
Your total costs for health care: You pay a monthly bill to your insurance company (a “premium”), even if you don’t use medical services that month. You pay out-of-pocket costs, including a deductible, when you receive medical care.
Plan and network types—HMO, PPO, POS, and EPO: Some plan types allow you to use almost any doctor or health care facility. Others limit your choices or charge you more if you use providers outside their network. It’s important to find out what the benefits and limits of your plan are so you don’t receive and surprise charges or bills.
Remember, plans also may differ in quality. Learn more about quality ratings, as well as preview and compare plans before you apply. You can also read additional tips for navigating the Marketplace here.
ABOUT BRAIN INJURY ALLIANCE OF ARIZONA
The Brain Injury Alliance of Arizona (BIAAZ) is the only statewide nonprofit organization dedicated to improving the lives of adults and children with all types of brain injuries through prevention, advocacy, awareness, and education. BIAAZ also houses the Arizona Brain Health Resource Center, a collection of educational information and neuro-specific resources for brain injury survivors, caregivers, family members, and professionals.
What began in 1983 as a grassroots effort has grown into a strong statewide presence, providing valuable life-long resources and community support for individuals with all types of brain trauma at no charge.
The Brain Injury Alliance of Arizona:
- Works with the Congressional Brain Injury Task Force
- Houses Arizona Brain Health Resource Center
- Hosts the Statewide Opioid Use Disorder & Cognitive Impairment Workgroup
- Deploys a Statewide Opioid Use Disorder & Cognitive Impairment Response Team with peer support, training and family wraparound services
- Facilitates the Brain Health Advisory Council
- Manages a Statewide Neuro Info-Line 888-500-9165