There are two main categories of health insurance - private and public.

1. Private Health Insurance: There are various types of private health insurance. Private plans are often sponsored by an employer, private plans may purchased directly from an insurance company, or private plans may also be purchased from insurance exchanges in participating states. There are two main types of managed care plans within private health insurance: HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization).

   HMO plans offer healthcare services through a network of healthcare providers. A “provider” may mean anything from doctor to physical therapists to hospitals to pharmacies, among other deliveries of healthcare services. Under an HMO plan, you must choose a primary care provider (PCP) within your network. The PCP is responsible for referring you to other specialists within your HMO network when needed. HMO plans only cover healthcare costs that are within the network. Since DM specialists are rare, it is unlikely that a person living with DM will have a specialist within their HMO network. Therefore, if you want to visit a DM specialist who is outside of your HMO network, you will need to get a referral to be seen out of network or pay for this visit out-of-pocket.

   A PPO plan offers a more extensive network of healthcare providers to choose from. PPO plans generally offer more flexibility for seeing out-of-network specialists than HMO plans, but premiums tend to be higher. PPO plans typically require higher monthly payments in exchange for increased flexibility. In addition, with a PPO, you don’t need to have a PCP. PPO plans often provide more freedom to visit DM specialists with a lower likelihood of having to pay out-of-pocket. If you have the option of choosing a PPO plan over an HMO plan and can afford the higher premium, it is recommended that you choose the PPO plan, because it will be more likely that services from out-of-network DM specialists will be covered.

   Additional health insurance plans include an EPO (Exclusive Provider Organization), POS (Point of Service), and HDHP (High Deductible Health Plans), which are often used in conjunction with Health Savings Accounts (HAS), and Catastrophic Health Plans.

   For more information about how these plans work, visit HealtchCare.gov's Health insurance plan & network types: HMOs, PPOs, and more.

   Health Insurance Plan Costs

   In addition to the monthly premium you pay for health insurance, there are other “out-of-pocket” costs that can impact your total spending on healthcare. When these other costs are factored in, they can sometimes be higher than the premium itself.

   Deductible: How much you must spend for covered health services before your insurance company pays anything (except free preventive services).

   Copayments and coinsurance: Payments you make each time you receive a medical service after reaching your deductible.

   Out-of-pocket maximum: The most you may spend for covered services in a year. After you reach this amount, the insurance company pays 100% for covered services.

   For more information about private health insurance costs, visit HealthCare.gov's Your total costs for health care: Premium, deductible & out-of-pocket costs.
    

2. Public Health Insurance: Federal and State programs that offer insurance, most commonly Medicare and Medicaid, are forms of public health insurance. These programs are for people who qualify based on their age, income, employment status, and/or whether or not they live with a disability. Some people may be eligible for both Medicare and Medicaid. Medicare pays covered medical services first for dual eligible beneficiaries because Medicaid is generally the payer of last resort. To learn more about the difference between Medicare and Medicaid, visit the Medicare Learning Network Booklet.

   Medicare is the federal health insurance program for people aged 65 and older who have paid into the Social Security system for a total of 10 years, people younger than 65 who are disabled, and people with ESRD (end-stage renal failure requiring dialysis or a kidney transplant). One important thing to know about Medicare is that unlike Medicaid, it does not pay for long-term care. For more information, watch this YouTube video about Medicare and long-term care.

   Medicare has four components, Parts A-D:

   Part A (Hospital Insurance):

   • Enrollment occurs automatically at age 65 with no premium charges. For individuals who did not pay into Medicare taxes while employed, Part A can be received by paying monthly premiums.

   • Part A provides coverage for inpatient hospital care, critical access hospitals, skilled nursing facilities, and hospice care.
      

   Part B (Medical Insurance):

   • Part B covers physician and outpatient services, including the services of physical and occupational therapists and home healthcare. Part B also covers durable medical equipment and some preventive services.

   • The standard Part B premium amount in 2020 is $144.60 a month. If your income is high, you may have to pay more.
      

   Part C (Medicare Advantage):

   • Part C provides extra coverage such as vision, dental, and wellness coverage. This is a health plan run by a private company that contracts with Medicare to provide both Part A and Part B benefits.

   • Out-of-pocket costs may be charged depending on which services are used.
      

   Part D (Prescription Drug Coverage):

   • Medicare Part D is also offered by private insurance companies approved by Medicare. Everyone with Medicare, regardless of income, health status, or prescription drug usage, has access to prescription drug coverage as of 2006. However, co-pays and costs vary by plan and medication. If you don’t have Part D, many state government human service agencies and local health centers can refer you to local organizations or prescription assistance programs that can help.
      

   If you are thinking about shopping for Medicare Part C or D, be sure to check out Medicare.gov.

   Medicare Supplemental Insurance (Medigap) can pay most of the 20% costs Medicare doesn’t cover. This supplemental insurance can help cover costs not covered under Medicare Part A and Part B. These types of policies are sold by private companies and can help cover the cost of copayments, coinsurance, and deductibles.

   The Medicare glossary explains key terms in the Medicare program. For more information about Medicare and how to enroll, visit the official Medicare.gov website. You may also reach out to the State Health Insurance Assistance Program (SHIP) in your state.

With 64 million people enrolled, Medicaid is the largest program providing medical health-related services and long-term care to low-income individuals and families. Medicaid was designed as a federal-state partnership to provide public funding for healthcare. States set income standards for adults without children. Parents of children are eligible for Medicaid if they meet income and asset standards. Medicaid provides benefits not typically covered (or covered to a lesser extent) by other insurers, including long-term services and supports. Medicaid also pays for Medicare premiums and cost sharing for more than 10 million people who are enrolled in both programs. In order to be eligible for Medicaid, your income must be below defined limits, usually set by the Federal Poverty Level (FPL).

The following services must be provided for individuals who are enrolled in Medicaid:

• Inpatient and outpatient hospital services

• Physician services

• Early and periodic screening, diagnostic, and treatment services for individuals under 21

• Nursing facility services for individuals ages 21 years and older • Home healthcare for people eligible for nursing home services

• Family planning services and supplies • Rural and federally qualified health clinic services

• Laboratory and X-ray services

• Pediatric and family nurse practitioner services

• Nurse midwife services

Many states have expanded eligibility for Medicaid to include people with incomes up to 138 percent of the federal poverty line. The goal is to provide health insurance to more people who would otherwise be without it because their incomes are too high. To enroll in Medicaid, visit this link to find your local office.

Children’s Health Insurance Program (CHIP)

If your income is too high for Medicaid, your child may still qualify for the CHIP. This program covers medical and dental care for uninsured children and teens up to age 19. CHIP qualifications are different in every state. In most cases, they depend on income. You can apply for CHIP through your state.

Other health insurance options include coverage under the Veterans Administration (VA) or TRICARE and Indian Health Services (IHS), if eligible.