It can be tough to navigate a new disease as a young adult, especially when it comes to finding good health insurance. With the high cost of care, getting the right coverage is essential.
If you’re not already covered under your parents’ or employers’ plan, you’ll likely have to look for coverage in the Health Insurance Marketplace, or from an insurance broker. Under the Affordable Care Act (ACA), marketplace plans can’t deny you or charge more for coverage when you have a disease like MS.
Some plans can have pricey premiums or deductibles. If you’re not careful, you could end up paying a lot more for your doctor appointments and medications than you expected.
Here are seven tips on how to navigate the sometimes tricky world of health insurance.
Insurance can be expensive, especially on an entry-level salary. It’s worth checking into whether you qualify for Medicaid. This federal and state program offers health insurance coverage at little or no cost to you.
Under the ACA, 35 states, including Washington, D.C., have expanded their eligibility to include a wider income range. Whether you qualify depends on the state you live in.
To find out if you’re eligible, visit Medicaid.gov.
If you don’t qualify for Medicaid, you might make the cutoff for a program that helps with health insurance costs. The government offers assistance in the form of subsidies, tax credits, and cost-sharing reductions when you buy a plan from your state’s marketplace. This financial assistance could significantly lower your premiums and out-of-pocket costs.
To qualify for reduced premiums, you must earn between $12,490 and $49,960 (in 2020). And to get help with your deductible, copays, and coinsurance, you need to make between $12,490 and $31,225.
The ACA has levels of coverage: bronze, silver, gold, and platinum. The higher the level, the more the plan will cover — and the more it will cost you each month. (Remember, you can save money on premiums at all levels if you qualify for federal assistance.)
Bronze plans have the lowest monthly premiums. They also have the highest deductibles — how much you’ll have to pay for medical care and drugs before your plan kicks in. Platinum plans have the highest monthly premiums, but they cover just about everything.
The basic bronze plans are designed for healthy people who only need health insurance in case of an emergency. If you’re on a regimen of MS drugs, you may need a higher tier plan. Consider how much you pay for medication and treatments when choosing a level.
If there’s a doctor you’ve been seeing for years, make sure they’re covered by the health insurance plan. Every plan includes certain doctors and hospitals. Other doctors are considered out-of-network, and they’ll cost you more per visit.
Look up all the doctors and specialists you currently see using the plan’s online search tool. Also, look up your preferred hospital. If your doctors and hospital aren’t in-network, you may want to keep looking for another plan.
By law, each plan in the Health Insurance Marketplace must cover 10 essential services. These include things like prescription drugs, lab tests, emergency room visits, and outpatient care.
Which other services are covered varies from plan to plan. While annual visits with your primary care doctor should be on every plan, things like occupational therapy or rehab may not be included.
How much you’ll pay for services can differ depending on the company you choose. And certain plans may limit the number of visits you get with specialists like physical therapists or psychologists.
Look on the plan’s website or ask an insurance rep to see its Summary of Benefits and Coverage (SBC). The SBC lists all the services the plan covers, and how much it pays for each one.
Each health insurance plan has a drug formulary — a list of drugs that it covers. Drugs are grouped into levels called tiers.
Tier 1 usually includes generic medications. Tier 4 has specialty drugs, including the pricey monoclonal antibodies and interferons used to treat MS. The higher the tier of the drug you need, the more you may have to spend out of pocket.
Check each of the drugs you currently take to treat your MS and other conditions. Are they on the plan’s formulary? Which tier are they on?
Also, find out how much you might have to pay if your doctor prescribes a new drug that’s not on the plan’s formulary.
When it comes to your future healthcare costs, premiums are only part of the puzzle. Get out your calculator as you compare plans, so you won’t be surprised by big bills later on.
Add up:
- your premium — the amount you’ll pay for health insurance coverage each month
- your deductible — how much you’ll have to pay for services or medication before your plan starts to kick in
- your copayment — the amount you’ll have to pay for each doctor and specialist visit, MRIs and other tests, and medications
Compare plans to see which one will give you the most benefit for your buck. When you re-enroll in a marketplace plan each year, go through this process again to make sure you’re still getting the best deal.
Choosing a health insurance company is a big decision, especially when you have a condition that involves costly tests and treatments, like MS. Take time to carefully consider your options. If you’re confused, call each insurance company and ask one of their reps to talk through the plan’s benefits with you.
If you don’t end up liking the health insurance plan you ultimately choose, don’t panic. You’re not stuck with it forever. You can change your plan during the open enrollment period each year, which usually happens in the late fall.