Cost and Coverage

The questions below can help you figure out what is included in a healthcare plan, what the copays and other out-of-pocket expenses are, and what the network of healthcare providers is like. Many of these questions would apply to someone of any sexual orientation or gender identity evaluating a plan, but we have also included targeted questions about the cultural competency of the providers and plan network in serving LGBT individuals and their families.

  1. Am I eligible for financial assistance to help me afford coverage? Am I eligible for lower premiums? Am I eligible for a reduction in my out-of-pocket costs?
  2. How much is the plan going to cost (beyond the monthly premiums)? What are all my out-of-pocket costs on the plan?
    1. Is there a deductible in this plan before coverage kicks in, and what is the amount of the deductible?
  3. Is there a wide network of providers on the plan?
    1. If you have a healthcare provider you would like to keep, ask if your provider is covered under the plan.
      • If you don't have a current healthcare provider, but would like to find an LGBT-knowledgeable provider, check out GLMA. They keep a list of self-identified providers with experience working with the LGBT community. Once you identify a provider on the GLMA list, you can ask which plans work for that provider. RAD Remedy is also available as a resource.
    2. Can I choose my primary care provider? Can I select a family practice nurse practitioner, midwife, or other kind of clinician as my primary healthcare provider?
    3. How many healthcare providers belong to this plan?
    4. What's the referral process within this plan? Do I need to go to my primary care provider to get a referral?
  4. Are there providers who specialize in working with LGBT individuals and families? What about with LGBT people of color?
  5. Does this plan provide any training about LGBT families and LGBT issues to its' providers? How does this plan ensure providers are culturally competent to serve LGBT individuals and their families?
  6. Immigration status & language access: To be eligible for health coverage in the health insurance marketplace you must be a U.S. citizen or national living in the United States. In order to be eligible for Medicaid, individuals need to satisfy federal and state requirements regarding residency, immigration status, and documentation of U.S. citizenship.
    1. Someone in my family needs language translation to access care. Does the plan provide translators who are both linguistically and culturally competent?
  7. How is urgent and emergency care covered in this plan?
    1. Are there urgent care facilities in this plan? What's the cost to me for a visit to urgent care?
    2. What's the cost for a visit to the emergency room in this plan? What about in-network vs. out-of network?
  8. Dental coverage: Dental coverage is not considered an essential health benefit for adults, and insurance plans are not required to offer it as part of plans in the marketplace. However, many companies offer stand-alone dental policies through the marketplace that you can purchase at the same time that you enroll in health insurance. Some Medicaid programs may choose to provide dental benefits and some marketplace health plans may provide dental services as a covered benefit.
    1. Does the plan include dental coverage?
    2. Can I purchase a stand-alone dental policy?
  9. Complementary Alternative Medicine: Does the plan cover complementary alternative medicine like acupuncture, naturopathic medicine, or chiropractic services?
  10. Smoking: Smoking: If you are a smoker or current user of tobacco, you should ask about how this affects the cost of the plan. Generally, an insurer can charge as much as 50% more for a person who uses tobacco products (although CA, MA, NJ, NY, RI, VT, and the District of Columbia have prohibited a tobacco surcharge on health insurance). If you report inaccurate or false information about your tobacco use on an application, an insurer is allowed to retroactively impose the tobacco surcharge to the beginning of the plan year.
    1. I use tobacco products. How does this change the cost of the insurance plan?
    2. I would like to quit using tobacco products. What kinds of services and programs are available?
  11. Does the plan cover medical equipment? If so, which equipment is covered and what limitations are there on equipment coverage?
  12. Does the plan cover personal care services? What about home health services? What is the maximum amount of services allowed?
  13. Does the plan cover skilled nursing facilities? What about hospice? What is the maximum amount of these services allowed?
  14. What kind of rehabilitation services, including physical, speech, and occupational therapy, are covered by the plan? What are the copays and other cost-sharing for these services? Is there a cap on the number of visits that would affect the care I need?
  15. Privacy and billing: If you have concerns about privacy, you might want to know how billing is handled in each plan.
    1. How is billing handled? Which services are explicitly named or billed separately?
  16. What forms of identification are needed for plan enrollment (driver's license, birth certificate, non-governmental identification)?

Questions in red are ones that assisters may not be able to answer because this kind of information is not gathered consistently from healthcare providers. However, we included them because we know that these kinds of questions can make a critical difference in creating a trusted relationship with your healthcare provider.