Making Best Use of Your Health Insurance Options
DISCLAIMER: Legislation, regulations, and policy details regarding health insurance change frequently. This article is intended as general education based on information current at the time of publishing. Can Do MS makes no guarantees of ongoing or current accuracy. Please consult an insurance specialist or attorney with specific questions.
Making sure you are enrolled in a health insurance plan at all times may be the single most important way to avoid debt and assure your ability to get the health care services you need. Many changes have been made to health insurance in recent years, including new protections for people with pre-existing and high-cost conditions like multiple sclerosis. Unfortunately, even comprehensive health insurance cannot guarantee full protection against high out-of-pocket costs or medical debt.
The key to using your coverage wisely and avoiding costly mistakes is being aware of:
Some key points about the types of health insurance most people use at different times in their lives are described below. Understanding these basic facts, resources and key terms will go a long way toward helping you predict and plan for the costs of care you and your family will need.
Employer-based GROUP Coverage
- Who is Eligible: Employees or union members (and often, but not always, their dependents), as determined by the employer or union.
- When to enroll: As soon as possible after employment begins, or during a Special Enrollment Period triggered by certain life events or circumstances (new baby, marriage, geographic move, and others). Note that waiting periods of up to 90 days are allowed before coverage takes effect, and re-enrolling each year is a common requirement.
- What’s Covered: Comprehensive benefits meeting federal standards are required, although limits on benefits and wide variations in prescription drugs and other benefits are typical.
- Helpful Resources: The employer or plan administrator; written plan materials provided by the insurer (may be online); Customer Service (see phone number on back of member ID card); or the National MS Society (1-800-344-4867).
- Common Errors: Missing enrollment deadlines; using an out-of-network doctor, hospital or pharmacy; not checking to make sure a drug, service or device is covered; not taking advantage of appeal rights if/when the insurer denies coverage for a prescribed treatment; not taking advantage of Patient Assistance Programs (if eligible) to help with out-of-pocket costs.
Individual policies (aka “non-group” coverage) via the Health Insurance Marketplace or off-Market plans
- Who is Eligible: Anyone under age 65 who is not eligible for employer or union Group coverage.
- When to enroll: Initial and annual enrollment periods (November 1 to January 31) and Special Enrollment Periods triggered by certain qualifying events.
- What’s Covered: Individual insurance plans must provide comprehensive benefits meeting federal standards, though limited quantities (such as ‘x’ number of physical therapy visits in a year) and variations in prescription drug and other benefits are typical.
- Helpful Resources: Federal or State Marketplace (Healthcare.gov); written plan materials provided by the insurer (may be in print or online); Customer Service (see phone number on back of member ID card); the National MS Society (1-800-344-4867).
- Common errors: Missing enrollment deadlines; using an out-of-network doctor, hospital or pharmacy; assuming that every drug, service or device that’s prescribed will be covered; not taking advantage of appeal rights; picking a plan based on low monthly premiums instead of whether it includes the providers and benefits best suited to your needs; not taking advantage of the cost sharing reductions and advanced premium tax credits that are only available through the Marketplace (www.healthcare.gov); failing to keep your Healthcare.gov file up-to-date with any changes in income, address or other factors that could impact the amount of your tax subsidy; not taking advantage of Patient Assistance Programs (if eligible) to help with out-of-pocket costs.
- Who is Eligible: People who meet at least one of three criteria: age 65 or above; have been receiving disability income payments from the Social Security Administration for at least two years; or, have a diagnosis of ALS or end stage renal disease (ESRD).
- When to enroll: Initial enrollment period is seven months long, beginning three months prior to your date of eligibility. Medicare will send enrollment information to your home at that time, or you can call for information at any time (1-800-MEDICARE). Eligibility begins immediately for people diagnosed with ESRD (after a four month waiting period) or ALS. The General Enrollment Period for those who missed their initial enrollment into Part B is from January 1st to March 31st for coverage beginning July 1st. The annual open enrollment period for those who miss their initial Part D enrollment or want to join a Medicare Advantage plan is October 15 to December 7th every year. Certain life events and circumstances may trigger a Special Enrollment Period.
- What’s covered: Medicare Advantage Plans cover everything that Original Medicare (A & B) covers, but the cost structure is different. Original Medicare covers hospitalization, inpatient rehab services and drugs administered during inpatient care through Part A. Preventive and primary care services provided by participating doctors and/or other health care professionals, labs, and diagnostic services are covered through Part B. All services are subject to limits and criteria for coverage. Long term care is never covered. Prescription drugs are covered separately by Medicare Prescription Drug Plans (Part D) and are only covered by Original Medicare during a hospital stay, and may be included in certain Medicare Advantage plans.
- Helpful Resources: Medicare.gov (1-800- MEDICARE); National MS Society (1-800-344-4867); State Health Insurance Programs or Medicare Rights Center National Helpline (1-800-333-4114).
- Common errors: Not knowing about penalties for late enrollment; Incorrect assumptions including thinking that every provider, service or device that is prescribed is covered, that long term care is covered, that care provided overseas is covered, and that appealing denials or limits in coverage isn’t worthwhile. Other mistakes: not planning for dependents’ coverage when employer coverage ends; not knowing how to coordinate Medicare coverage with employer, retiree or other coverage, not taking advantage of Medicare Savings Programs.
- Who is Eligible: Medicare beneficiaries that are NOT enrolled in a Medicare Advantage plan and NOT eligible for a Medicare Savings Program. Medicare beneficiaries may not purchase individual policies from the Marketplace to supplement Medicare coverage.
- When to enroll: Applying within first six months of enrollment in Medicare Part B and age 65 or older assures you will not be turned down due to health and will have greatest number of plans to choose from. State laws vary for beneficiaries under 65.
- What’s Covered: Depending on the plan, Medicare Supplemental plans can cover out-of-pocket costs NOT covered by Original Medicare including annual deductible, premium, copays or co-insurance, but only for benefits covered by Original Medicare, and the amount of coverage varies significantly from plan to plan. Medicare Supplemental plan benefits are standardized by federal law and designated by letter (currently A to M), with generally greater benefits provided by more expensive plans.
- Helpful Resources: Medicare.gov (1-800- MEDICARE); National MS Society (1-800-344-4867); State Health Insurance Programs; your State Department of Insurance; Medicare Rights Center National Helpline (1-800-333-4114).
- Common errors: Missing enrollment deadlines and/or assuming enrollment is available anytime; not taking advantage of Medicare Savings Programs.
- Who is Eligible: Anyone eligible for Medicare Part A and without qualified prescription drug coverage from another source (aka Creditable Coverage).
- When to enroll: Initial enrollment periods vary depending on how a person has gained eligibility for Medicare, and anyone who does NOT enroll within 63 days of their initial eligibility period faces a late enrollment penalty. The annual open enrollment period for those who miss their initial enrollment period, or who wish to change their prescription drug plans, is October 15th to December 7th of each year.
- What’s covered: Prescription drugs listed on the plan’s formulary or non-formulary drugs if an exception request or appeal of a denial of coverage is successful.
- Helpful Resources: Medicare.gov or 1-800-MEDICARE; Medicare Plan Finder; National MS Society (1-800-344-4867).
- Common errors: Not enrolling when first eligible, not researching and enrolling in the best plan for you, not taking advantage of the low income subsidy, assuming financial assistance from a patient assistance program is always available.
Medicaid and Medicaid waiver programs:
- Who is Eligible: Anyone that meets income, and in some states, additional criteria.
- When to enroll: Any time of year through Healthcare.gov or agency designated by the state.
- What’s covered: Full Medicaid includes comprehensive primary, preventive, medical, hospital, prescription drug and long term care benefits that vary by state and subject to limits imposed by the state or administrative entity. Copayments may be required for some benefits in some states. Some states offer “Partial” Medicaid benefits through special waiver programs to help eligible individuals pay for specific needs, such as home care.
- Helpful Resources: Healthcare.gov; Medicaid.gov; your state’s Medicaid agency
- Common errors: Assuming you/your loved one is not eligible due to lack of awareness of waivers or other special programs; lack of coordination when a Medicaid enrollee is also insured through a retiree plan, Medicare, the VA, or another source;
Veterans and Armed Services Health Benefit Programs:
- Who is Eligible: Eligibility for active duty and retired service members and family of the Army, Navy, Marine Corp, Air Force, Coast Guard, Public Health Service, or National Oceanic and Atmospheric Administration are determined by each program and subject to additional criteria under various circumstances.
- When to enroll: Enrollment is mandatory for those in active duty and processed upon entering the service, dependents can explore their enrollment options at that time, but may have to seek coverage from another source.
- What’s covered: Preventive care services; ambulatory (outpatient) diagnostic and treatment services; hospital (inpatient) diagnostic and treatment services; Women Veterans’ Unique Needs; some may also qualify for long-term care services such as VA Community Living Centers, State Veterans Homes and additional services such as geriatrics and extended care, adult day health care, respite care, home health care, hospice and more.
- Helpful Resources: www.VA.gov/healthbenefits, VA Health Benefits toll-free 1-877-222-VETS (8387); Your local VA health care facility’s Enrollment Office, National Association of County Veteran’s Service Officers - http://nacvso.org/ and http://nacvso.org/find-a-service-officer/; Paralyzed Veterans of America.
- Common errors: Not exploring all options and different eligibility for different members of the household (as some may be eligible for VA or TRICARE benefits as well as employer group benefits, Medicare, Medicaid or other); lack of understanding about different levels of VA or TRICARE benefits.
More Tips on Health Insurance
Use the Information Your Health Plan Must Provide
All health insurance plans are required to disclose important facts and explanations about members’ benefits and rights. These include: a Summary of Benefits and Coverage; for network plans, a directory of the doctors, hospitals and other providers in the network; an Explanation of Benefits (EOB) detailing charges, and amounts the insurer and you are responsible for paying; ; a list of the prescription drugs on the formulary; and information about one’s right to appeal denials of coverage for prescribed treatments.
Don’t Miss Out on Special Cost Help Programs
Many people are unaware of cost-help programs that can significantly lower out-of-pocket costs for those who qualify. Although the application processes mean more paperwork and coordination effort for individuals or their caregivers, many people with MS rely on these programs and have greater peace of mind about their finances as a result. Drug manufacturers often offer help with copayments or co-insurance for qualified individuals who rely on their products; tax credits and cost-sharing reductions can make health care more affordable for individuals and families who buy coverage through Healthcare.gov; and Medicare beneficiaries can learn more about programs specifically for them through their State Health Insurance Program.
Job Changes and Health Insurance
One of the most important job benefits an employer can offer is a health-care plan. Because MS is a lifelong condition, carefully consider the health benefits provided by an employer before accepting a position.
Don’t ask to see the benefits package during the first interview, but when offered a job, ask to review the package before giving an answer. When reviewing the health-care portion of the employer’s benefits package, pay particular attention to the plan benefits, excluded benefits, the provider network and prescription drug formulary. Before switching to a new employer’s health-care plan, find out when your new coverage will take effect and plan accordingly. There could be a waiting period of up to 90 days—or you could be covered the first day you report to work.
Try to avoid a gap in your medical coverage. If you have to wait to join a new employer’s health-care plan, try to bridge the gap with one of the options described below.
Considerations when reviewing a health care plan:
- Coverage for MS care, including the drugs and healthcare services you now use. Are your MS specialists in the provider network? If not, are others? Is your drug listed on the formulary? Are there limits on some of the benefits you are likely to need, such as ‘x’ number of physical therapy or mental health visits covered in a year?
- Type of plan. Some employers give you a choice between different types of health-care plans. Read about each type, and choose the plan that is best for your chronic condition as well as the routine medical needs of you and your family. Ask yourself questions such as, “Can I still go to my current doctor/hospital? Am I satisfied with my choice of doctors and hospitals? Will I be able to get care from specialists when I need it?”
- Costs. If you are choosing between health-care plans, compare the costs of co-pays or co-insurance amounts, prescription drugs, your share of the premiums, and ask for help if necessary. Keep in mind that an inexpensive health-care plan may not be the least expensive in the long run after you consider coverage limits, excluded benefits, annual deductibles, or other out of pocket costs.
Options for Bridging the Gap Between Health -Care Plans
The best way to plan for future medical costs is to ensure that you have exhausted all of your options for accessing health insurance for everyone in your household. If you are switching jobs, are no longer a student, get separated or divorced, are waiting to become eligible for Medicare due to a disability, or face the loss of health insurance for any other reason, there are likely options for you. Are you eligible for a parent or spouse’s employer-based plan? Or an individual plan from the Marketplace or directly from an insurance company or broker? Can you continue your group health benefits through COBRA? Again, it is always best to compare all of your options before enrolling, or re-enrolling, in any plan.
The Consolidated Omnibus Budget Reconciliation Act of 1985 (referred to as COBRA) allows you and your covered dependents to keep your previous employer-based group health-care plan for 18, 29, or 36 months, depending on the circumstances, if a “qualifying” event occurs. This federal law applies to employers with 20 or more employees, and states often have similar laws for even smaller employer groups.
COBRA is helpful, but there is a catch. You must pay the full cost of coverage, at the employer’s group rate, plus up to 2 percent to cover administrative fees. If that cost seems steep, keep in mind how much more expensive it would be to pay for MS treatment without a health-care plan or with a costly individual plan.
Because paying to continue your group health coverage through COBRA is expensive, you should also look into buying your own individual insurance policy through the Marketplace or even directly from an insurance company with the help of an insurance broker to see if that offers a better option. Bear in mind that tax credits and cost-sharing subsidies for individuals are only available when coverage is purchased through the Marketplace (Healthcare.gov). Additionally, you can only enroll in Marketplace coverage during the Open Enrollment Period (November 1 to January 31st) each year, unless you qualify for a Special Enrollment Period triggered by certain life events including getting married, having a baby, or losing employer health coverage for any reason.
Insurance programs for children and students
Making sure your children are insured is easier since major health care reforms were enacted. Young adults up to age 26 are now able to join, or even re-join, a parent’s employer-based group plan. Individual ‘child only’ insurance policies are available through Healthcare.gov for children if they are not eligible for a parent’s employer-based plan. The Children’s Health Insurance Program (CHIP) provides coverage for un-insured children up to age 19 from lower income households, and colleges and universities typically offer health plans for their qualified students.