Health insurance options

Health insurance coverage comes either from private companies or from federal or state governments. The kind of health insurance you have depends on your financial background, work status, age, and health or disability status. The kind of plan you have may impact:

• Which doctors you can see
• Your out-of-pocket (OOP) expenses
• The costs you must pay on your own

Private insurance

If you have employer-sponsored health insurance, you bought a plan directly from an insurance company, or you got insurance through the health insurance marketplaces established by the Patient Protection and Affordable Care Act (ACA), you have private health insurance. It’s important to know which type of coverage you have. The types of private insurance are:

Health Maintenance Organization (HMO)

With an HMO:

• You are usually limited to in-network providers who have a relationship with the insurance company.
• If you use an out-of-network provider, it is likely that your insurance carrier will not pay for the services except in an emergency.
• You may be required to live or work in the HMO’s service area to be eligible for coverage.

Point-Of-Service (POS) Plan

With a POS plan, you pay less for in-network providers. Your PCP will be required to give you a referral to see other doctors in the network.

Preferred Provider Organization (PPO)

A PPO supplies a list of preferred providers; you pay less if you use these providers. Generally, you do not need a referral to see a specialist. You can used providers outside of the network, but you will pay an additional cost.

Fee-For-Service (FFS) Plan

With an FFS plan, providers are paid for each service, including tests and office visits, provided.

State Health Insurance Marketplaces/Exchanges

Through the ACA, if you are uninsured or underinsured, you can buy private insurance through your state’s Health Insurance Marketplace/Exchange. Trained navigators, or guides, can help you find the best plan for you and your family. They can also help you figure out if you qualify for any financial help, such as premium tax credits or cost-sharing subsidies. The amount of aid you receive is based on your income.

Depending on where you live, you can access a marketplace run by your state, or one run by the federal government. Visiting healthcare.gov will direct you to the correct marketplace for your state.

Using the marketplace, you can shop for insurance and compare plans and prices during the annual open enrollment period or a special enrollment period.

Plans are sorted based on the price of the monthly premium and how much of your healthcare costs the plan is expected to cover.

Plans are categorized into four “metal levels” — bronze, silver, gold, and platinum. The difference between these categories is based on the plan’s share and your share of costs for covered services. Estimates of the plan’s share and your share of costs can be found at healthcare.gov.

You can shop for private health insurance outside the government marketplace, but keep in mind:

• You will not be eligible for financial help for the premiums.
• You may come across coverage options that are not compliant with the ACA. That means they may not meet the standards for you to be considered covered based on ACA rules. These plans:
  • May not cover essential services required by the ACA
  • Can charge you a higher premium based on your health history
  • Can place caps on how much of your care is covered

State-run insurance

Your state government may offer health insurance plans tailored to your specific needs. Some states offer coverage based on your job — for example, to public school teachers or government employees.

Federal insurance

The federal government manages health insurance options for people who meet special criteria. The two most widely used federal healthcare programs are Medicare and Medicaid.

After work-sponsored private insurance, Medicare and Medicaid are the most common ways Americans get health coverage. In 2022, nearly 20% of the U.S. population was enrolled in Medicaid and nearly 20% was enrolled in Medicare for at least part of the year.

Medicare

You may be eligible for Medicare if you are age 65 or older, or if you are under 65 and have certain disabilities and you’ve been getting Social Security Disability Income for 24 months.

Medicare plans have deductibles and coinsurance that you will have to pay.

Medicare, like private insurance, has several kinds of coverage that offer different benefits. For all plans, you must make sure your healthcare provider is a Medicare provider. Here is an overview of Medicare:

Part A: Hospital insurance

Part A (hospital insurance) helps cover hospital care, nursing facility care, home health care, and hospice. Most people do not pay a monthly premium for Part A because they paid Medicare taxes while working. If you receive Social Security or Railroad Retirement Board benefits (for at least 4 months before turning 65), you will automatically be enrolled in Parts A and B when you turn 65, or after getting Social Security Disability Insurance for 2 years at any age.

Part B: Medical insurance

Part B (medical insurance) helps cover necessary medical services such as doctor appointments, outpatient care (not requiring hospitalization), medical equipment, home health services, and some preventive care. Part B is voluntary and requires payment of a monthly premium that is determined by your income. You can opt out of Part B when you become eligible for Medicare, but you will pay a penalty if you decide to enroll later unless you have creditable coverage.

To learn about the Initial Enrollment Period and the General Enrollment Period for Medicare Part A and Part B, visit medicare.gov.

Part C: Medicare Advantage

Part C (Medicare Advantage) plans are offered by private insurance companies approved by Medicare and bundle Parts A, B, and sometimes C. Part C covers all the expenses A and B cover, as well as other services like vision, hearing, and dental. Most people with Part C plans also include Medicare prescription coverage (Part D).

Medicare Supplement Insurance (Medigap). These policies are sold by private insurance companies to help pay for healthcare costs that Original Medicare doesn’t cover. Medigap policies vary by state. It’s best to buy a plan as soon as you qualify for Medicare. The protections provided by the ACA don’t apply to Medigap plans, so if you wait, Medigap plans can deny coverage or charge more if you have a preexisting medical condition.

Some states allow people with Medicare who are under 65 to buy a Medigap policy. In some states, “People under 65 who don’t initially get a Medigap policy have another chance to get it when they turn 65,” says Aimee Hoch, MSW, LSW, OSW-C, FACCC, Grand View Health Cancer Center’s financial navigator.

Medigap Open Enrollment is a one-time period of 6 months that starts the first month you have Medicare Part B and you’re 65 or older. During this period, you can join any Medigap policy and the insurance company cannot deny coverage if you have a preexisting condition. After this period, you may not be able to get a Medigap policy, or it may cost more.

Here are some other things to know about Medicare Part C:

• If you choose a Medicare Advantage plan, you will choose among HMO, PPO, FFS, or Special Needs plans, and pay a premium and other out-of-pocket (OOP) expenses. There may be other Medicare Advantage plans available to you.
• Annual open enrollment takes place in the fall (October 15 through December 7). This is also a time when people can review and/or make changes to their Part C coverage. There are also special enrollment periods, or SEPs, throughout the year that allow people who qualify based on certain life events, like moving to a new home or losing other coverage, to make changes to their coverage.

Medicare Savings Programs. You can also apply for help with Medicare A and B premiums and other costs through your state if you qualify. There are four different savings programs offered. Information about these programs can be found on the Medicare website.

Part D: Medicare prescription drug coverage

Part D (Medicare prescription drug coverage) is available to everyone with Medicare A and/or B. Part D offers an initial enrollment period and an annual enrollment period for people who decline initial enrollment (though you may have to pay a penalty if you select this option, unless you have creditable coverage).

Here are some other things to know about Medicare Part D:

• Annual open enrollment takes place in the fall (October 15 through December 7). You can add or stop your Part D coverage during this time. This is also a time when people can review and/or make changes to their Part D coverage. There are also special enrollment periods, or SEPs, throughout the year that allow people who qualify, based on certain life events like moving to a new home or losing other coverage, to make changes to their coverage.
• The Inflation Reduction Act (IRA) is a law that went into effect in 2022. It has enabled Medicare to negotiate for prescription drug prices and limit OOP prescription drug costs. As of 2025 the limit for people enrolled in Part D is $2,000 for OOP prescription drug costs.
• The Medicare Prescription Payment Plan offers people enrolled in Part D the option of paying OOP prescription drug costs in capped monthly installment payments instead of all at once. Participation is voluntary; you must opt in.
• Medicare also offers a Low-Income Subsidy, also called “Extra Help,” to aid people enrolled in Medicare Part D who have limited resources. Extra Help provides help paying for copayments and deductibles for prescription drugs. Some people are automatically eligible, and some need to apply.
• Due to the IRA, there will no longer be a coverage gap (donut hole) or catastrophic coverage stage. Since 2006, when Medicare Part D went into effect, higher limits ($5,030 in 2024) forced Part D enrollees to enter a coverage gap, also called the “donut hole.” People in this gap phase paid a discounted price for OOP costs until they met an $8,000 limit. Once they reached that limit, they left the coverage gap. That means they could get help paying for prescription drugs in the “catastrophic coverage” stage for the rest of the calendar year.

If you have recently enrolled in Medicare or are looking for more information about navigating the program, visit the State Health Insurance Program, or SHIP, for one-on-one help.

Medicaid

Medicaid is a joint federal and state program that helps cover medical costs for Americans with limited income and resources.

With Medicaid:

• The program is managed by each state, so eligibility and benefits will vary depending on where you live.
• In any state, you may be eligible for Medicaid based on your income, family status, household size, disability, and other factors.
• Some states offer hospice benefits.
• Most states expanded Medicaid eligibility when the ACA went into effect. This means that if you live in one of those states (or the District of Columbia), you may qualify based on income alone.
• Eleven states have not expanded Medicaid. They are Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming.

Contact your state Medicaid agency, local Department of Social Services, or the Centers for Medicare and Medicaid Services for more information.

National Breast and Cervical Cancer Early Detection Program

Through the National Breast and Cervical Cancer Early Detection Program, the Centers for Disease Control and Prevention (CDC) provides screening and diagnostic services to low-income, uninsured, or underinsured women for free or at very little cost. The program is funded in 50 states; Washington, D.C.; Puerto Rico; five Pacific islands affiliated with the U.S.; and 13 American Indian/Alaskan Native tribes or tribal organizations.

If you were diagnosed through this program, you are eligible to have your treatment covered by Medicaid. In some states, even if you were not diagnosed through this program, you may still be able to have your treatment covered by Medicaid.

Children’s Health Insurance Program (CHIP)

The Children’s Health Insurance Program (CHIP) offers low-cost health coverage for children to families whose income does not qualify them for Medicaid. Like Medicaid, CHIP is run by your state, which sets rules for eligibility and coverage. In some states, you may be eligible for CHIP if you are pregnant or have children.

Talk to a financial navigator or social worker at your doctor’s office or your state’s department of health and human services to learn about the program. Information can also be found at medicaid.gov.

Other ways to get health insurance

If you weren’t insured before your breast cancer diagnosis or you lost your health insurance for any reason, it can feel overwhelming to think about paying for care. Help is available – you just have to know where to look.

A patient navigator, financial navigator, or social worker can help you find health insurance coverage, local services, and government programs in your state.

Other insurance options

There are some other ways you may be able to get health insurance coverage, including:

• The Consolidated Omnibus Budget Reconciliation Act (COBRA), a federal law that allows you and your family to continue employer-based group insurance on a short-term basis.
• Veterans’ healthcare benefits. Contact the Department of Veterans Affairs (VA) at va.gov or (877) 222-8387 to find out if you are eligible.
• Some unions, civic groups, and associations.
• Employers. Many employers offer group health coverage.
• A spouse. If your spouse has work-sponsored insurance plan, you are eligible to join.
• A domestic partner. While domestic partnerships do not receive the same federal rights as spouses, some states and employers may offer coverage to domestic partners.
• Your parents, if you are under age 26.