September 14, 2021

HOC Insurance 101 Series- Part 2

More Fun Insurance 101!

Last time we discussed some of the common terms associated with insurance coverages.  Let’s start Part II looking at the different sources of healthcare coverage or where you can obtain coverage for your healthcare needs.  After that we will look at when you can enroll in the different plans.

  • Group Coverage through an Employer

One common way to obtain insurance is through your employer. Many employers offer group coverage to their employees. Usually, you will be able get insurance for yourself, your spouse, and/or your family.  Typically, there is cost sharing involved where you pay a portion of the premium which could come out of your paycheck pre-taxed.  Under current law, if the plan covers children, they can stay on the policy until they turn 26 years old, even if they are married and/or not living with their parents.  These are usually commercial insurances such as Anthem Blue Cross Blue Shield or United Healthcare.

  • Health Insurance Marketplace

If you are employed at a workplace that doesn’t offer health insurance, there is another way to find affordable healthcare coverage.  In 2010, the Affordable Care Act established the “Health Insurance Marketplace.” Also known as the Marketplace, or the Exchange, this is a shopping and enrollment service for medical insurance for individuals and families.  In most states, the federal government runs the Marketplace, although some states run their own Marketplaces at different websites. You can check it out different insurance plans available in your area online at

  • State Medicaid Programs

Medical Assistance (Medicaid) is a type of healthcare coverage that is available in every state. Eligibility is based on income.  Each state manages their own guidelines and levels of coverage.  There is no open enrollment for Medicaid so you can apply at any time.  An important note is that not all providers accept Medical Assistance so you will want to check before going to a provider to see if they accept Medical Assistance coverage.  To find out more about Medicaid, you can go to

  • Medicare

Medicare is a federal health insurance program for people in the U.S.  To be eligible for Medicare, you must be 65 and older or have a qualifying disability.

When you become eligible for Medicare, it is very important to take a look at what your needs are at that time because there are many different scenarios, some of which include penalties for delaying enrollment.

Traditional Medicare includes 2 separate types of coverage, commonly known as Part A (This benefit helps pay for inpatient care at hospitals and also short-term skilled nursing facilities.  Typically, there is no premium owed if you’ve earned enough credits from payroll taxes through your years of employment.) and Part B (This benefit helps pay for most all other medically necessary outpatient and provider services, tests, etc. Part B only covers 80% of allowed charges.  There is a premium owed, which is deducted from your Social Security payment each month.)

In addition to Parts A and B, you are also required to have coverage for your drugs, which is commonly called Part D. Part D plans can be purchased separately, but since traditional Medicare does not pay 100%, you will want to look at purchasing a supplemental plan to help with the coinsurance amounts.  Most supplemental plans (also known as Medigap plans) include the necessary drug coverage.

Medicare Advantage Plan (Medicare Part C). This is another option to choose when you are eligible for Medicare instead of going with traditional.  These types of plans are subsidized by the federal government but coverage is through commercial insurance companies like UnitedHealthcare or Blue Cross Blue Shield.  Your Medicare premium is still deducted from your monthly Social Security and you may have an additional amount owed if you choose a higher level benefit plan. These advantage plans will usually include coverage for inpatient hospital, physician and drugs. There are many different plans that are available depending on where you live.

With the exception of State Medicaid (where eligibility is based on income), all insurances have open enrollment periods.

What is Open Enrollment and what does it have to do with me?

Open enrollment is the time period when you are allowed to start, stop, or change your health insurance plan. Whether your insurance coverage is through your employer, the Marketplace, or because you are of age to qualify for Medicare, it is important to know when your open enrollment period starts/ends.  It is during this time you can make changes to your coverage. Why would you want to do that?  Many reasons. Your healthcare needs may have changed and a different plan will better cover those needs. Premiums may have increased or there are other plans that have better premiums offered.

Most of the time open enrollment is during the last quarter of the year for the new coverage to start the next full year. However, this is not written in stone. Medicare has very strict enrollment periods defined for when you are initially eligible and there may be penalties if you don’t sign up during this period.  Also, some employers may have fiscal year that ends mid-year instead of year-end and their insurance plans run the same way.  Ask if you aren’t sure when open enrollment is because you don’t want to miss the opportunity to take a look at how your healthcare will be covered in the next year.

Now that we’ve looked at the where and when to obtaining insurance coverage, we will be ready to get down to the nitty gritty.  Next time, let’s explore how to review your insurance choices to make a decision on the best option available to you.  We will look at this from the perspective of someone living with a bleeding disorder where we know that healthcare can be quite expensive.  It might be surprising that the option that looks to be the favorite at first may not be the best choice in the end.

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