How health insurance works


How health insurance works

Inflammatory bowel diseases (IBDs) are chronic conditions that require frequent monitoring, testing, and treatment. Obtaining health insurance to cove

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Inflammatory bowel diseases (IBDs) are chronic conditions that require frequent monitoring, testing, and treatment. Obtaining health insurance to cover health care costs can be challenging for those who need it most. There are a variety of public and private health insurance options to help individuals and families get affordable health care.

Read on to learn more about public and private health insurance options.

Private Options:

Group Insurance Group

insurance is health insurance you get from an employer, union, or through a spouse’s employer or union. The employer compares the available plans, selects the insurance carrier, and chooses plan options for the employees. Coverage depends on the individual’s employment (or the employment of their family member).

Individual Insurance

These plans are purchased by an individual to cover themselves or their family. As an individual, you can select insurance from individual insurance companies or the health insurance marketplace. Individual insurance plans have a variety of options, but costs and offerings can vary from state to state.

Health Insurance

Marketplace The Health Insurance Marketplace (also known as the Health Insurance Exchange) provides information about health insurance options, compares insurance plans, and allows you to apply for coverage. This is useful if you don’t have coverage or want to explore more cost-effective options. All plans in the marketplace are considered qualified health plans, which means they must cover Essential Health Benefits (EHB), including but not limited to outpatient services; emergency services; hospital coverage; behavioral health; prescription drugs; laboratory services; and chronic disease management. These plans may be subsidized by the government based on your income. The market offers affordable options, but these may be limited in what they cover. 

Association Health Plans (AHP)

Association Health Plans (AHPs) are health insurance plans run by small employers that come together to form an association. A 2018 Trump administration regulation expanded the scope of small employers and self-employed individuals who are allowed to participate in AHP. AHPs are not subject to the same regulations and patient protections as health insurance exchange plans. AHPs must provide preventive care and allow people under the age of 26 to continue to have their parents’ insurance. People with pre-existing conditions are not allowed to charge more but can base premiums on gender, age, location, and occupation. AHPs are not required to cover essential health benefits, 

Short Term Limited Duration Health Plans ( STLDHPs

) Short Term Limited Duration Health Plans (STLDHPs) are health insurance plans that are intended to fill a short gap in insurance coverage. steps are not required to uphold patient protections like exchange plans. steps can deny coverage and charge more based on health status, impose annual and lifetime limits, and choose not to cover essential health benefits. Earlier this year, the Trump administration extended STLDHPs from less than three months to 364 days, with the option for consumers to renew plans for up to three years. 

Public health insurance:

These health insurance plans are run by the government. Public health insurance plans include:


Medicaid is a state-run health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities, and, in some states, other adults. The federal government provides a portion of the funding and sets guidelines for Medicaid. States also have options in how they design their program, so Medicaid programs and eligibility vary from state to state, and may have a different name in your state. People qualify for Medicaid based on their family size and income and can apply at any time of the year. Visit for more information.


Medicare is a federally run health insurance program available to people 65 years of age or older, younger people with disabilities, and people with End-Stage Renal Disease. Visit or call 1-800-MEDICARE (1-800-633-4227) for more information.

Medicare Part A is hospital insurance that helps cover inpatient care in hospitals, skilled nursing facilities, hospices, and home care.

Medicare Part B helps cover medically necessary services like physician’s care, outpatient care, home health, and other medical services, as well as some preventive services. Most Medicare beneficiaries are automatically enrolled in Part B. This part of Medicare generally covers the costs of biological infusion products but often has coinsurance that is the patient’s responsibility to pay.

Medicare Part C, also known as a Medicare Advantage Plan (MAP), is a type of health plan offered by a private insurance company and approved by Medicare to provide you with all the benefits of Medicare Part A and Part B. There are many types of MAPs, including Health Maintenance Organization (HMO) plans, Preferred Provider Organizations (PPOs), Private Fee-for-Service Plans, Special Needs Plans and Special Needs Plans. Medicare Medical Savings Accounts. Medicare services are integrated with the health plan so that the health plan’s benefits are coordinated with Medicare Parts A and B. Most Medicare Advantage plans offer prescription drug coverage.

Medicare Part D is an optional program that provides prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare prescription drug plan (Part D) or through a Medicare Advantage plan that includes drug coverage. These plans are offered by insurance companies and other private companies, as approved by Medicare. Part D generally covers the costs of biological products for injection but is subject to the coverage gap (below), which can lead to high out-of-pocket costs.

The Medicare Part D coverage gap is a period when you don’t have coverage from your Medicare Part D plan. Medicare Part D consists of four stages of coverage:

  • Deductible – If your plan has a deductible, you generally pay the full cost of your drugs up to the deductible amount.
  • Initial Coverage – During this stage, the plan pays its share of the cost and you pay a copayment or coinsurance (your share of the cost) for each prescription you fill until your total drug costs reach $3,750 (this changes from year to year).
  • Coverage Gap – During this stage, you have exceeded your plan’s initial coverage limit, so the amount you pay for your prescription drugs increases. If you’ve noticed that you’re suddenly paying more for your prescriptions, you may find yourself in the coverage gap. This stage continues until your yearly out-of-pocket drug costs reach $5,000 (this changes from year to year).
  • Catastrophic Coverage – In this stage, you have reached the coverage gap and pay 5% coinsurance for each prescription you fill.
  • Every January 1, your coverage resets to the Deductible Stage (if your plan has a deductible) or the Initial Coverage Stage (if your plan does NOT have a deductible).

Low-Income Subsidy (LIS) or “Medicare Extra Help Program”

LIS is for Medicare Part D beneficiaries and Medicare/Medicaid dually eligible beneficiaries who have limited income and resources to help pay for prescription drugs. LIS provides financial assistance to patients who may not otherwise be able to pay the costs associated with their Medicare Part D plan. People who are eligible for the LIS can:

  • Get help paying your monthly premium
  • Get a reduction in the deductible or not pay it
  • Get a reduction in copays and coinsurance for prescription drugs or not pay for them
  • Bypassing the coverage cap and donut hole

For assistance with insurance-related to Medicare, contact the Medicare Rights Center at 800-333-4114. You can also contact the Medicare Advocacy Center at 860-456-7790

Most states have counseling programs that can provide free information and assistance about Medicaid/Medicare, commercial insurance, and other types of health care financing. The Families USA website is a helpful place to find health care resources in your state.

Senior Insurance Information

It’s never too early to start thinking about your Medicare options. If you’re nearing retirement or turning 65, it’s important to start thinking about your health coverage options.

The Initial Enrollment Period (IEP) for Medicare begins three months before your 65th birthday and ends three months after your birthday. The date your Medicare coverage begins depends on the date you sign up.

Coordinated or supplemental Medicare insurance

Enrolling in coordinated or supplemental health insurance can help eliminate out-of-pocket costs. There are two options to consider.

Medigap is private insurance that covers the gaps between your Medicare benefits and what you must pay out of pocket. You buy Medigap plans from private insurance companies to help pay for things Medicare doesn’t pay for, like copays, coinsurance, and deductibles.

Medicare Part C, also known as a Medicare Advantage Plan (MAP), is a coordinated care plan, which means your Medicare benefits are integrated into the Medicare Advantage Plan.

Instead of paying for Parts A, B, and D, a person would enroll in Medicare Advantage through a private insurance company that, in many cases, covers everything provided by Parts A, B, and D and may offer additional services. . The beneficiary would pay the Medicare Advantage premium along with the Part B premium in most cases.

It is strongly recommended that patients with IBD consider applying for supplemental or secondary coverage, such as Medicare Part C (Medicare Advantage) or Medigap, to help pay for some of the costs not covered by Original Medicare.