It can be complicated to manage a chronic health condition like multiple sclerosis (MS), especially when it comes to finding health insurance. Given the high cost of care, getting the right coverage is essential.

In the United States, living with MS carries a heavy financial burden. Read on to learn about options like private health insurance, Medicaid, and Medicare and how they apply to managing MS.

Many private insurance plans cover treatments associated with MS, but the specific amount of coverage will vary based on your plan.

If you are not already covered through your employer or under a spouse’s or parent’s 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. It’s important to read all the plan details, or you could end up paying a lot more for your doctor appointments and medications than you expect.

You may also qualify for coverage under Medicare or Medicaid, depending on your age and income level. Here’s what to know about all types of health insurance coverage in the United States and what you should consider when it comes to managing MS.

In the United States, most people qualify for private insurance through their employer when employed full-time. However, if this isn’t the case for you, you can still buy private insurance at HealthCare.gov, also known as the Health Insurance Marketplace.

The ACA has four levels of coverage:

  • bronze
  • silver
  • gold
  • platinum

The higher the level, the more the plan will cover. But it will also cost you more 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. A deductible is how much you’ll have to pay for medical care and prescription medications 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 people who only need health insurance in case of an emergency. If you’re on a regimen of MS drugs, though, you may need a plan in a higher tier.

Consider how much you need to pay for medication and treatments when choosing a plan level. You may also want to consider factors like long-term physical or occupational therapy needs and whether you’ll need inpatient, outpatient, or hospital care.

Insurance can be expensive, so it’s worth checking whether you qualify for Medicaid. This may be the case if you are unable to work due to MS.

Medicaid often provides partial coverage for expenses not covered by Medicare or other health insurance plans, such as long-term care in a nursing facility or at home. The program has no age restrictions.

To qualify for Medicaid, you must earn at least $20,783 as of 2024, but this can vary slightly from state to state. Under the ACA, 41 states, including Washington, D.C., have expanded their eligibility to include a wider income range.

To find out whether 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. This financial assistance could significantly lower your premiums and out-of-pocket costs. To qualify, you need to earn approximately $21,870–$29,160.

Medicare offers health insurance coverage to people who are at least age 65 years, as well as those receiving disability insurance benefits from the Social Security Administration (SSA) for at least 24 months. Having MS as the reason for your disability benefits qualifies you for Medicare.

Under Medicare, you can choose between original Medicare or a Medicare Advantage plan that offers lower costs in exchange for using in-network providers.

Both options cover the same services, but they may differ in limits and out-of-pocket costs. Original Medicare includes Part A for hospital and in-patient care and Part B for doctor visits, lab fees, and outpatient equipment usage. In addition, Medicare Part D should cover medications used to treat MS.

In some cases, you might still have some out-of-pocket costs with Medicare, such as copayments or deductibles. To offset this, you can also consider getting Medigap. This might be a private insurance plan, but the insurer cannot refuse coverage to any person over 65 years old with a preexisting disability.

Depending on what type of insurance you qualify for, if you’re living with MS, it’s important to consider the following before selecting a plan:

Is my doctor in network?

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, so they’ll cost you more per visit.

Look up all your current doctors and specialists 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.

Are my doctor visits, tests, or hospitalizations covered?

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.

Are my medications covered?

Each health insurance plan has a drug formulary — a list of drugs 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 not on the plan’s formulary.

Is assistive equipment covered?

If you need assistive devices of any kind, it’s a good idea to take this into consideration as well before selecting your plan.

Most insurance plans will cover durable medical equipment (DME), such as wheelchairs, in some capacity.

That said, depending on your plan, it’s a good idea to check before signing up and to verify whether you might need to request approval from your doctor in order to get the coverage.

What are my total out-of-pocket costs?

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.

Add up your:

  • Premium: This is the amount you’ll pay for health insurance coverage each month.
  • Deductible: This is how much you’ll have to pay for services or medication before your plan starts to kick in.
  • Copayment: This is 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.

Is MS covered under critical illness insurance?

Critical illness insurance is a supplemental plan that can help you cover anything that your main insurance company doesn’t.

There are different types of critical illness plans, and they’re mostly private. Some give you a lump sum for anything you want, while others support you with incremental payments.

If there are things you need as part of your MS treatment that your regular insurance plan does not cover, you may be able to use this for that purpose. Most of these plans cover neurological conditions like MS.

Where else can I get financial support?

If you’re living with MS, some resources may help you pay for treatments in addition to any insurance coverage you may have. This includes:

Choosing a health insurance company is a big decision, especially when you have a condition like MS that involves costly tests and treatments.

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.