Hi guys,
I currently have Medicaid and have only had Medicaid since being an adult. I have switched jobs and will make more money so I will not qualify for Medicaid. I’m sure coverage will end before the year is up because Medicaid is like that (they’ve ended my coverage midway through the year before).
I’m having to search plans on marketplace now, so how would I see what each insurance plan offers? I 100% need coverage for hormone replacement therapy, which I get monthly. Secondary needs would be: mental health therapy, primary care physician visits, dental, these general health upkeep things.
I’ve asked someone, and they said they think the only option is to have to call each company individually to ask benefits. Is this true?? Thanks
23M, Louisiana
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Dental won’t be covered, so you’ll need a separate dental plan. While it’s not the only option, it’s probably the best one. However, you should adjust your expectations—Marketplace insurance won’t cover things like Medicaid does. You’ll have deductibles and out-of-pocket maximums to consider.
For what you want, expect a high premium, possibly hundreds of dollars a month. Does your insurance offer healthcare?
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Hi there willow2,
I definitely don’t want to pay hundreds of dollars a month since going from $0 to that is tough. Honestly, I’m not making much more money than before. But I know I won’t qualify for Medicaid based on the requirements. As for my new job, they only offer insurance after a year of employment with an average of 30 hours per week. My top priority is getting hormone replacement therapy and the necessary appointments covered.
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Did you get the option to list all your medications for HRT on the marketplace? I did, and when I checked plan details, it showed if my medications were covered or not, along with alternatives that were covered. For example, Prometrium wasn’t covered for me, but Progesterone was.
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Thanks, I’ll look for that option when I apply. I haven’t applied yet because I’m unsure what to put for my annual income since I just started a tip-based job. I need to talk to my boss about how to estimate it because I’ve never had a job with tips before.
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You need to find the “Medical Contract” or “Medical Policy” for each plan. Sometimes it’s linked on the marketplace page, but other times you’ll need to search the insurance company’s website, usually in member documents or provider resources. This contract outlines what’s covered and excluded, and it’s usually 70+ pages long, so use CTRL+F to search for specific care types.
Marketplace plans cover essential health benefits, including outpatient mental health. For medications, check the formulary, which lists covered drugs and their price tiers. Make sure you select the right document for your plan and year.
Dental isn’t covered under health insurance, so you’ll need a separate dental policy. Some find it more cost-effective to pay cash for dental care, but that depends on your needs.
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If your income is relatively low, you might qualify for a significant premium subsidy and possibly a Silver Tier Plan, which offers extra help with medical costs.
Visit your state’s official marketplace to see available plans and costs based on your estimated annual income. Remember, “covered” doesn’t mean free—insurance plans have deductibles, co-insurance, and co-payments. Check out the stickie on this sub/reddit for a clear explanation of these terms and to better understand the pros and cons of different plans.
Also, insurance coverage depends on “medical necessity.”
If your hormone replacement relates to sexuality concerns, consider reaching out to a local organization for specific advice on coverage, as they likely handle similar questions often.