Choosing a health insurance plan doesn’t have to make you cringe.

As we head into another health insurance enrollment season, the Affordable Care Act Marketplace ( and Medicare—Beyond Type 1 are here for most employer-provided coverage. To help you navigate the overwhelming array of options.

HMO versus PPO, high deductible versus low deductible. First of all, what do these acronyms stand for? So how do you know what’s best for you and your family’s health needs?

Next, we will explain how to enroll and what you should consider depending on the type of coverage you have or want to obtain. You can also visit the Guide to Medical Insurance for T1D if you are looking for more information on the elements of coverage you can consider.


Open enrollment is the annual period when people can openly enroll in health insurance plans on the Affordable Care Act Marketplace, also known as the Healthcare Exchange or, to next year. The enrollment period opens on Monday, November 1, and closes on Saturday, January 15, 2022. This is a unique extension for 2022 coverage only due to the COVID-19 pandemic. That’s an eleven-week window to secure care for next year.

It’s a six-week window to secure health care for the following year.

Suppose you don’t enroll by January 15. In that case, you’ll only be able to get 2022 coverage if you qualify for one of the marketplace’s Special Enrollment Periods, such as a life event like losing work-based health insurance, getting married, having a baby, or losing insurance in a divorce or separation. People who qualify for Medicaid or the Children’s Health Insurance Program (CHIP) can apply for coverage at any time.

Plans purchased during open enrollment begin January 1, 2022. You can apply using this checklist and enroll here starting Monday, November 1.

The most important thing to keep in mind is that a plan with lower initial costs (i.e., your monthly premium) may end up costing more money overall because it may have less coverage for your necessary drugs and supplies.

Be sure to pay close attention to the plan’s prescription drug/pharmacy coverage. Coverage for durable medical equipment and deductible.

So what are the options and their most significant differences?


HMO stands for “Health Maintenance Organization.” These plans provide access to doctors and hospitals within a network established by your insurance plan. Networks are made up of providers who have agreed to provide your health services at the prices they have negotiated with the insurance company.

This often means providers are paid less than the insurer than they might typically get. They make this concession because of the easy access to large numbers of patients that the plans provide.

The lower cost sounds good. Well, that’s right. In exchange for accepting the limitations of an HMO (discussed below), patients typically pay lower-paid monthly premiums (your monthly fee for having insurance). Deductibles (the amount you pay out of pocket before your insurer starts paying your health care costs) also tend to be lower.

The biggest drawback of HMO plans is that they only contract with many doctors and hospitals in an area. Insurers will not pay for medical care received from out-of-network providers. So if you go out of network, you’ll suddenly find yourself with massive health care costs.

When you join an HMO plan, you must choose a primary care physician at that time. Next, you must get a referral from your primary care doctor before seeing any specialists. It is important to note that some health services, such as annual screening mammograms, do not require a referral. Usually, though, you’ll need a referral, which often means you have to visit the office before the office visit you’re looking for.

Other HMO drawbacks include an annual limit on the number of office visits, tests, and specific treatments.

Choose an HMO plan if lowering health care costs is your top priority. While you’ll face limits on who you can see based on your plan’s network, your monthly premiums and deductibles will be lower. However, keep in mind that you’ll need to get referrals for specialist services, and there may be annual plan limits on office visits and certain health services.


PPO stands for “Preferred Provider Organization.” These plans offer much more leniency when seeing out-of-network health care providers without a referral. In general, you can see who you want whenever you want. The hurdle: That freedom and flexibility usually come with higher costs.

Like their counterparts, PPO plans also establish provider networks. The plans have fewer restrictions on going out of network. With most PPO plans, you can also skip the referral process and make an appointment with a specialist (an endocrinologist, for example, for those with Type 1 diabetes). You don’t have to take the step of seeing your primary care doctor and rack up another office visit first.

But it’s essential to be aware of the cost consequences of going out-of-network and remember that seeing an out-of-network provider will generally cost more than staying in-network. While PPO plans include an out-of-pocket maximum for in-network care, money spent out-of-network generally doesn’t count toward that limit. That means you’ll find yourself paying, paying, paying for health care services. PPOs also typically have higher premiums and higher deductibles.

Choose a PPO plan if you want the flexibility to go out of network and avoid referrals and if you’re the type of patient who uses their health care services regularly and has a need to see specialists.


For most people, Medicare eligibility is based on age. You can enroll during a window that begins three months before the month you turn 65 and ends three months after the month of your birthday, or you can enroll during Medicare Open Enrollment, which is Friday, October 15, 2021, through Tuesday. December 7, 2021, for 2022 coverage.

During that initial window of eligibility, you can enroll in traditional Medicare. Which is the government’s fee-for-service health plan with two parts (A for hospital insurance and B for medical insurance), or Medicare Advantage, a health plan Medicare offered by a private company that contracts with Medicare and offers Parts A and B. You can also sign up for supplemental coverage or choose a drug plan. Under the Patient Protection and Affordable Care Act, having Medicare Part A is sufficient to meet the law’s requirements for minimum essential coverage.

If a Medicare plan covers you, this open enrollment period is the only time you’ll be able to make changes to your coverage, so it’s worth reviewing your plan to see if any changes need to be made.

Traditional Medicare, the government fee-for-service health plan, has two parts (A is for hospital insurance and B is for medical insurance). Medicare Advantage is a Medicare health plan offered by a private company that contracts with Medicare and offers Parts A and B. You can also sign up for supplemental coverage or choose a drug plan (Part D).

Under the Affordable Care Act, having Medicare Part A is enough to meet the law’s requirements for minimum essential coverage. Still, if you live with diabetes, it’s more cost-effective to be covered by Part B, and Part B. Part D. Medigap plans are supplemental plans that offer more help with costs.

A key difference for 2021 was the new Medicare Part D senior savings model. In these plans, out-of-pocket costs for insulin are capped at $35 per month with no deductible. However, not all programs offer this cap on insulin costs, and only those who take insulin through syringes or pens qualify. Although the same insulin is often used, those who inject insulin through an insulin pump are considered to be taking “infused medication,” so insulin used through an insulin pump is covered under Part B Medicare and does not offer an insulin cost limit.

You can sign up for Medicare online, over the phone by calling 1-800-MEDICARE (1-800-633-4227), or by going to your local Social Security office. Medicare Advantage plans are sold through private insurers. To find Medicare plans, use the Plan Finder. Be sure to select that you want to see your drug costs when you compare plans and choose to add the brand name to each of your insulin prescriptions instead of adding the generic name. As you reach each project, click “view drugs and their costs” to find out what your actual out-of-pocket costs will be before and after your deductible.


The types of plans offered by the employer are very similar, if not often the same, like the programs offered through the Health Exchange, but the employer will usually cover part of the cost as part of its benefits package. Employees. Many companies offer various levels of coverage, which you can choose based on your personal needs. To learn more about what to consider when selecting a plan, visit the Guide to health insurance for people with T1D.

By Cary Grant

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