Multiple Sclerosis (MS) and Your Health Insurance Plan - dummies

Multiple Sclerosis (MS) and Your Health Insurance Plan

By Rosalind Kalb, Barbara Giesser, Kathleen Costello

Given the high cost of healthcare in the United States, insurance coverage is particularly valuable for anyone with multiple sclerosis (MS). It may, in fact, may become one’s most valuable asset, because the costs related to managing this disease can be extremely high.

To take best advantage of your health coverage, you need to make careful choices based on the cost and practical implications of the following factors:

  • Who’s covered under the policy — employee, spouse, dependents? (Those who are covered are considered qualified individuals.)

  • Is this a managed care plan in which you can save money by going to in-network doctors, hospitals, and pharmacies? Is it worth it to you to see MS specialists who aren’t in the network? Do you know exactly how the referral system works and how much more expensive it may be to use specialists that aren’t in the network?

  • Is there a waiting period before a qualified individual is covered? Is there a period of time during which your MS or other preexisting condition will not be covered? If yes, how long?

  • How much is the annual deductible? Is it for each family member separately, or for the whole family in combination? Is there a separate deductible for prescription drugs or other services?

  • How much of the cost of covered services (co-insurance percentage) do you have to pay after the deductible has been met? Is there a fixed dollar amount (co-payment) for services such as doctor visits?

  • What are the renewal conditions? Under what circumstances can your health plan (or employer or union) increase your premium?

  • Is there a stop loss provision that limits the amount of your out-of-pocket expenses? If yes, what’s the maximum out-of-pocket amount you would have to pay for the deductible, co-insurance, and co-payments per year before the plan begins picking up the full tab?

  • Is there a maximum amount that the health plan will pay while you’re eligible for coverage? If you have had annual limits on certain benefits or feared you may hit your lifetime cap on coverage, you may no longer have to worry. The Affordable Care Act is phasing out those limits for most health plans.

  • What services, medical equipment, and supplies are covered — for example, physical therapy, occupational therapy, mobility aids?

  • What’s the prescription drug benefit? Are there tiers of drugs that require different co-insurance or co-pay amounts (as is happening increasingly with the approved disease-modifying medications)? Are all of your medications included in the formulary?

  • Does the health plan have arrangements with a mail-order pharmacy or medical equipment supplier that could save you money?

  • What isn’t covered by the policy? For example, are there limits on:

  • Your choice of hospital and the number of covered hospital days? Are other hospital expenses covered?

  • The amount paid for doctor visits, including in-network and out-of-network doctors?

  • The number of visits or the amount of annual coverage for mental health benefits?