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5 signs you might need a different health plan
The insurance you have now may not be what you need next year. Here are some reasons to think about changing plans.
But health insurance isn’t just about care when you’re not feeling your best. It can also protect you from having to pay big medical bills. Maybe you have a health emergency. Or you might just be getting a routine checkup. Either way, you’ll know that some or all your costs may be covered by your plan.1
You may also want to change your plan at some point. In fact, as many as 20% of people switch their coverage every year.2 There are many things that might spur a change. For example, if you need surgery next year, you may want more coverage. Or maybe you’re turning 65, which means you may be switching from a commercial insurance to Medicare.
Some good news: You have choices when it comes to changing plans. Here’s a brief look at how you can do that.
When can I change health insurance plans?
Here are the different types of health insurance and when you can change your plan:
Affordable Care Act (ACA): If you’re getting your health plan through the Affordable Care Act (ACA) marketplace, you can change plans once a year, during open enrollment. (The ACA marketplace is a government-run website where you can buy insurance.) Open enrollment is a set period when you can sign up, renew your current plan or choose a different one.
Generally, open enrollment lasts from November 1 to January 15.3 But it can be different in some states. For example, in California, ACA open enrollment lasts until January 31. Be sure to check with your insurance company or state’s health office.
Employer-sponsored health plan: If you get your insurance through an employer, you’ll also have an open enrollment period when you can change plans. But that will likely be different from company to company. So, check with your human resources (HR) department for the exact timing.
Medicare: Medicare is a health program run by the federal government. It’s available to Americans 65 or older, or people who have end-stage kidney disease, amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig’s disease) or certain disabilities.
You get a chance to enroll in Medicare when you turn 65. That’s called an Initial Enrollment Period (IEP)4 (more on that below). If you miss your IEP window, you can sign up during the yearly General Enrollment Period from January 1 to March 31.4
Medicare also has an open enrollment period from October 15 to December 7 each year. If you’re already enrolled in Medicare, you can make changes to your plan during this time.5
Special Enrollment Period (SEP): Another time you can change your insurance is when you have a major life event. That’s called a Special Enrollment Period (SEP). You can get an SEP if you get married, have a child or lose your health insurance, among other reasons.6 There’s a different kind of SEP for ACA and Medicare, which we’ll discuss in a bit.
Even if you like your current health plan, it might benefit you to shop around. Or maybe you can’t wait to get a new plan. Whatever the case, here are five signs that you might want to consider getting a new plan.
Sign #1: You’re adding someone to your health plan
Did you get married last year? Right after your wedding, you would have had an SEP.6 But your spouse may have decided to stay on their own plan last year. If they want to be added to your plan now, they’ll have to wait until open enrollment to do that. And you can both be covered as early as January 1.7
You’ll want to choose a plan that meets both of your health needs. For example, you may only go to the doctor a few times a year. But maybe your spouse has a chronic condition, such as diabetes, and they make regular visits with a specialist. In that case, you might want more coverage.
All those extra doctor’s visits can add up. So, you may want to choose a plan with a higher monthly bill (premium) and lower deductible (that’s the amount of money you pay out of pocket before your insurance kicks in). If you have that type of plan, that means you’ll have to pay less upfront for health services, like doctor’s visits, before your insurance covers the rest.
Sign #2: You’re removing someone from your health plan
Let’s say you’re getting a divorce. If your spouse was on your plan, now you’ll have one less person who needs to be covered.8 You’ll get an SEP if you get a divorce, and you can change to a different plan then.
Or you can stick with your old plan. But make sure your insurance company knows it’s only you on the plan. That can save you money on your monthly insurance bill.
You might also need to take your adult child off your plan when they turn 26.9 They’ll get an SEP, which allows them to get coverage. But you’ll want to notify your insurance company. That may save you cash on your monthly insurance bill too.
One tip about that child of yours: You might consider moving them off your family policy even before they turn 26. That’s according to Martine Brousse, a patient advocate and medical reimbursement expert in Culver City, California. After age 18, kids are eligible to buy an individual policy through the ACA Marketplace.
“If they don’t have coverage through school or work, it actually could be cheaper for them to buy their own Marketplace plan rather than paying monthly bills under the umbrella of their parents’ policy,” says Brousse. That’s something worth looking into.
Sign #3: Your health needs change
Some years, you’ll hardly see the doctor at all. But other years, you might need to see them more often. It’s tough to predict broken bones or a surprise illness. “But there are certain things you can foresee based on medical services you’ve used in the last year or two,” says Brousse.
She suggests reviewing your current health plan to see if the coverage matches your needs.
You may need more coverage if you:
- Know that you’ll need a big surgery next year, such as a knee replacement or cataract surgery (that’s a type of eye surgery)
- Need regular medical treatments
- Plan to become pregnant
- See lots of doctors and specialists
If you have few health issues, you may not need expensive coverage. “Say you’re young, you’re healthy, you eat well, and you go to the gym,” says Brousse. You likely wouldn’t need to use your plan as much. So, it might make more sense to have a plan with a lower monthly bill. “Then, whenever you need care, you’d pay for the deductible or have a share of the cost,” she says.
Sign #4: You’re losing coverage
You could lose health insurance coverage for many reasons. These include:
- You decide to quit your job and start your own business.
- You get a divorce (and you were covered under your spouse’s plan).
- You lose your job.
- You turn 26 and are no longer on your parents’ plan (see above).
Thankfully, all these situations trigger an SEP. So, you’ll have a chance to find new insurance outside of open enrollment. That could be through the ACA Marketplace, where you may be able to get a discount based on your income. If you had insurance through an employer, there’s a law called COBRA that lets you stay on that plan for a period after you leave your job. (You need to pay the full cost of the premiums under COBRA.)
If you can’t afford a plan through the Marketplace, that’s OK too. You might be eligible for Medicaid. Have kids? They may be eligible for the Children’s Health Insurance Program (CHIP). It provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid.10,11
Sign #5: You’re turning 65
If you’re turning 65, you’re automatically eligible to enroll in Medicare. You can sign up for Medicare Part A (hospital insurance) any time after you turn 65. Your Part A coverage starts six months after you sign up or when you apply for benefits from Social Security (or the Railroad Retirement Board). Your coverage can’t start earlier than the month you turned 65.5
Here are some other scenarios where you can change your Medicare coverage:
- After your initial enrollment window closes, you can only sign up for Medicare Part B (doctor insurance) during the annual general enrollment (see above).
- An exception to that rule would be if you get an SEP, which is different for people with Medicare. For example, maybe you lost Medicaid coverage on or before the first of the year. You’ll get a chance to sign up for Medicare Part B. But enrollment is only open for a short window, and if you miss it, you’ll have to wait for general enrollment.5
- Let’s say Medicare doesn’t provide you with enough coverage. Case in point: It doesn’t come with prescription drug coverage. You have to pay extra for that.12
During AEP, you can also change your plan to Medicare Advantage (also called Medicare Part C). You buy it through a private insurer, and it offers the same coverage the government’s plan does. Plus, most MA plans include drug coverage, often at no extra cost.13
Interested in exploring what MA plans are all about? At Optum, you get personalized care to help you meet your health goals. That’s why more than 4 million people trust our doctors and Medicare Advantage. Learn more.
- CMS.gov. The Value of Health Insurance. Published September 2022. Accessed September 29, 2023.
- JAMA Network Open. Trends in Disenrollment and Reenrollment Within U.S. Commercial Health Insurance Plans, 2006–2018. Published February 24, 2022. Accessed September 29, 2023.
- Medicare.gov. Mark open enrollment dates on your calendar. August 24, 2023. Accessed October 12, 2023.
- Medicare.gov. When does Medicare coverage start? Accessed October 2, 2023.
- CMS.gov. Medicare open enrollment. Last updated September 6, 2023. Accessed October 12, 2023.
- Healthcare.gov. Special enrollment opportunities. Accessed September 29, 2023.
- Healthcare.gov. A quick guide to the Health Insurance Marketplace. Accessed September 29, 2023.
- Healthcare.gov. Qualifying life event (QLE). Accessed September 29, 2023.
- Healthcare.gov. People under 30. Accessed September 29, 2023.
- Healthcare.gov. New, lower costs on marketplace coverage. Accessed September 29, 2023.
- Healthcare.gov. Medicaid & CHIP. Accessed September 29, 2023.
- Medicare.gov. Drug coverage (Part D). Accessed September 29, 2023.
- Medicare.gov. Your health plan options. Accessed September 29, 2023.
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