Health Insurance Marketplace Guide for Asthma and Allergies for 2023

Allergies & Asthma

If you have asthma or allergies, it is important to have health insurance. Costs for medicines, lab tests, lung function tests, and visits to see a specialist all add up. What do you need to know about your insurance options during open enrollment this year?

Open enrollment refers to when you can add, change, or switch health insurance plans. For people who get health insurance through work, your employer and the insurance company set the dates for open enrollment periods.

The Affordable Care Act (ACA) makes health insurance more affordable and available to people without insurance benefits through their employer, Medicare, Medicaid, or another source. It includes other important provisions for people with allergic diseases. For example, if you buy a Marketplace plan, you cannot be denied because you have a pre-existing condition, such as asthma.

How Do I Enroll in a Health Insurance Plan?

If your job offers health insurance benefits, you will need to follow your employer’s instructions on how to enroll.

If you do not have health insurance benefits from your employer, or if you are uninsured, you can apply through the Marketplace. You can preview and compare plans before you choose a plan.

Here is a checklist of what information to have on hand to help you make a decision:

  • Your household size
  • Home and/or mailing address for everyone needing coverage
  • Information about everyone needing coverage, like birth dates and Social Security Numbers
  • Information about any professional person who is helping you apply (e.g., agent or broker)
  • Information on how you plan to file your taxes in 2023
  • Income information, such as pay stubs and W-2s for every member of your household
  • Policy numbers from your current health care plans
  • Estimated household income in 2023
  • Completed “Employer Coverage Tool” if anyone in your household can get insurance through an employer
  • Notices from your current Marketplace plan, if you had one for 2022
  • Documents for legal immigrants and naturalized citizens in your household

Healthcare.gov also has a checklist to help you get ready to apply.

Automatic Re-Enrollment

If you had Marketplace coverage last year, find out if you are set up for automatic re-enrollment. Even if you are, consider shopping for a new 2023 plan. You might find a new plan that offers better savings.

If you don’t update your application and choose a plan by Dec. 15, 2022, you may be automatically enrolled in a 2023 plan. Log in during the enrollment period, update your application, and review your plan options for 2023.

When looking at plans on the Marketplace, you can choose to “estimate total yearly costs.” To do so, you will be asked to select the level of care you expect to use this year. It’s OK if you end up using more or less. This won’t change your premiums or cost-sharing, or limit how many services you can use.

You might select “Low Use” if you expect:

  • Few doctor visits
  • Occasional prescription drugs
  • No expected hospital visits

You might select “Medium Use” if you expect:

  • Regular doctor visits
  • Regular prescription drugs
  • No expected hospital visits

You might select “High Use” if you expect:

  • Frequent doctor visits
  • Frequent prescription drugs
  • At least one hospital visit

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What Is Important to Consider If I Have Asthma or Allergies?

  1. Are your current health care providers in-network, such as your primary care doctor and your specialists?
  2. Does the plan include care from an asthma and allergy specialist?
  3. What medicines are covered by the plan? Look for the drug list or formulary.
  4. Does the health insurance plan require a referral required to see a specialist? Be aware that the number and type of plans will vary by states. Some states may have a wide choice of plans. Others may offer a health maintenance organization (HMO), which may require you to get a referral to see a specialist.
  5. What kind of treatments for asthma or allergies are covered by the plan?
  6. Will the plan pay for more advanced treatments, or will it limit the kind of treatment you can receive?
  7. Does the plan cover diagnostic tests for diagnosing asthma or allergies, such as lung function tests and skin prick testing?
  8. Will the plan cover medical devices such as spacers and nebulizers?
  9. Does the plan offer an asthma management program? Under program “details,” you can see if the health insurance plan covers asthma management. Many plans do. Asthma management programs may include a nurse hotline, help identifying your asthma triggers, assistance understanding your medicine, or using equipment like nebulizers and spacers.

What Are the “Metal” Categories in the Health Insurance Marketplace?

ACA plans fall under the categories of Bronze, Silver, Gold, and Platinum. The levels have nothing to do with quality. They refer to how you and your insurance plan split costs, known as cost-sharing.

Chart1-How-you-and-your-insurance-plan-split-costs (1)

Consider Silver if you qualify for extra savings on out-of-pocket costs, or if you want more of your costs covered.

  • If you qualify for extra savings (“cost-sharing reductions”), your deductible will be lower, and you’ll pay less each time you get care. These extra savings are only available through the Silver plan. This can save you hundreds or even thousands of dollars a year if you use a lot of care. Silver carries moderate premiums and deductibles.
  • While a Silver plan may have a monthly premium that’s higher than a Bronze plan’s premium, be sure to consider the total cost of your medical care. Your total costs include not just monthly premiums but the payments you make when you get care.
  • If you have a Silver plan and qualify for extra savings, the deductible can be thousands of dollars less than a typical Bronze plan’s deductible. So, you may end up spending less on health care overall if you enroll in a Silver plan.

Consider Gold or Platinum if you expect a lot of health care visits or need regular prescriptions.

These plans generally have higher monthly premiums but pay more of your costs when you need care.

What Are Advance Premium Tax Credits?

Advance premium tax credits (APTC) can help lower the cost of your monthly premium. Whether or not you qualify depends on your household size and household income.

When you apply for coverage through Healthcare.govHealthcare.gov, you will find out instantly if you qualify for this credit or not. You can also quickly check if you might qualify on their website without an application.

For example, this comparison shows an estimated cost for a Silver plan for a hypothetical 55-year-old woman in Arizona with low income ($22,000) who qualifies for the APTC:

healthcare-plans

The government may pay your tax credit directly to the insurance company, lowering the cost of the monthly premium that you pay out of pocket. Or you may choose to pay the full premium amount and get a refund at the end of the year.

What If I Have Low Income?

When you apply for coverage, you will also find out if you qualify for:

  • Medicaid
  • CHIP (the Children’s Health Insurance Program)

Both provide free or low-cost health coverage for some people, including low-income adults, children, pregnant women, seniors and people with disabilities. Medicaid provides insurance to more than 70 million Americans.

These programs may be known by different names in each state.

You may still qualify for your state’s program even if you don’t qualify for Medicaid based on income. You should apply, especially if you have children, are pregnant, or have a disability. You can enroll for Medicaid any time of year. Medicaid and CHIP have no open enrollment periods.

I Have Insurance Through My Job. Should I Look at the Marketplace?

You can, but the Marketplace is intended for people without health insurance. Since the ACA was passed, job-based health insurance must meet certain standards. You will pay full price for a Marketplace plan unless your coverage through work does not meet those standards.

Should I Buy “Catastrophic” Coverage, Short-Term Insurance or Hospital-Only Coverage?

The Catastrophic health plans may look like health insurance, but they do not meet the minimum standard for ACA plans or job-based health plans. For instance, they will not include prescription medicine or preventative care, both of which are important for people with asthma and allergies.

These health plans are available for:

Will I Pay a Penalty If I Don’t Buy Health Insurance?

As of 2019, you no longer have to pay a tax penalty if you are uninsured. But you might still be subject to a state tax penalty.

How Can I Get More Help While Applying?

Enter your zip code or city and state and get connected to someone who can help you locally.

Where Can I Learn More?

AAFA’s advocacy resources has more details about health care coverage and insurance issues, including Medicaid, Medicare and CHIP.

MyHealthPlan offers information about how insurance works.

Updated November 2022

It is important to stay up-to-date on news about asthma and allergies. By joining our community and following our blog, you will receive ongoing information about managing your health. Our community also provides an opportunity to connect with other people who manage asthma and allergies.

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