Navigating the Complexities of the Healthcare System

Choosing health insurance each year can be an overwhelming and frustrating process for everyone, but for people with MS, it can be even more daunting.  The complexity of plans, the uncertainty of what treatments or specialists will be covered, and the need for consistent, specialized care make the process overwhelming.  Balancing premiums, medication costs, and access to neurologists and therapies is crucial, but the process can feel uncertain and stressful.

How to Choose the Right Plan for You

Let’s explore some key factors that can simplify the decision-making process and guide you toward choosing the right plan to meet your specific MS care needs.

First let’s explore the different types of health insurance that might be available depending on your situation.

• Employer-Sponsored Coverage – also known as employer-provided health insurance, is health insurance offered to you and your dependents through your job. Your employer may offer a choice of group health plans to eligible workers and cover part of the monthly premium.
• Cobra – Consolidated Omnibus Budget Reconciliation Act – gives workers and their families, who lose their health benefits, the right to choose to continue group health benefits provided by their group health plan for limited periods of time (usually 18-36 months.) under certain circumstances such as voluntary or involuntary job loss. https://www.dol.gov/general/topic/health-plans/cobra
• Marketplace – Affordable Care Act (ACA) or Exchange – this offering is for those Individuals, Families and Small Business (up to 50 employees) that do not have health coverage through any of the other offerings on this list. It is operated by the federal government, available at https://www.healthcare.gov/ When applying you’ll provide income and household information. You’ll also be asked your state, as some states run their own Marketplace.  When going to https://www.healthcare.gov/ you will be directed to the correct website after entering your information.
• Young Adult under 26 – if your parent’s plan covers dependents, you usually can get added to or stay on your parent’s health plan until you turn 26 years old. You can remain or join even if you are: Married, a parent, not living with your parents, attending school, not financially dependent on your parents, or eligible to enroll in your employer’s plan.
• Veterans – The Department of Veterans Affairs provides a Medical Benefits Package if you served in the active military, naval, or air service and didn’t receive a dishonorable discharge. https://www.va.gov/
• Medicare – is a federal health insurance for anyone 65 years or older and some people under 65 with certain disabilities or conditions. (Original Medicare, Supplements and Medicare Advantage Plans) https://www.medicare.gov/
• Medicaid – is a joint federal and state program that helps cover medical costs for some people with limited income and resources. Each state runs their own program, making eligibility requirements and benefits vary from state to state. https://www.medicare.gov/

Different Types of Plans Available

Once you have figured out where you can get your health insurance, the next step is what type of plans are available to you. You might have come across the term “network” or “provider network” or acronyms like HMO, PPO, EPO, POS, but it may not be clear how choosing one over the other changes access to medical care and may affect your out-of-pocket costs. Let’s look at some differences.

• HMO (Health Maintenance Organization)- this plan contracts with a group of local providers to offer certain health care services. Members of an HMO plan are limited to this local network for their care needs.
  • HMO plans require that you choose a primary care provider (PCP).
  • You must get a referral through your PCP to see a specialist.
  • There is no out-of-network coverage with HMO plans (unless for emergency care).
  • Usually HMO have lower premiums, deductibles and cost shares.
  • No need to file health insurance claims.
• PPO-Preferred Provider Organization-this plan refers to its network of contracted PPO providers, offering the lowest out-of-pocket cost, compared to out-of-network providers.
  • PPO can have a large, nationwide provider network.
  • May have higher monthly premiums.
  • No requirement to choose a primary care provider.
  • No referrals needed.
  • Out-of-network coverage – but be aware that costs are higher compared to utilizing in-network providers.
  • More paperwork than with other plans if using out-of-network providers. You’ll need to pay the provider then submit a claim for the plan to pay you back.
• EPO-Exclusive Provider Organization- this plan is like a combination of HMO and PPO. EPO offers the freedom to see any network provider without a referral and you don’t have to pick a primary care provider. EPOs don’t offer out-of-network care.
  • No referrals needed.
  • No requirement to choose a primary care provider.
  • Generally lower out-of-pocket costs than a PPO plan.
• POS–Preferred Provider Organization– is a less common type of insurance. It partners with clinics, hospitals and doctors to provide care. If you stay within the network, your PCP will manage care, but you can go outside the network and seek care from a doctor of your choosing.
  • Staying in the plan’s network will help save money.
  • More providers to choose from.
  • Out-of-network coverage at a higher cost.
  • Premiums are higher than HMOs, but lower than PPOs.
  • You still may need your PCP to make referrals.

How Different Health Insurance Costs Work

It’s important to understand how different health insurance costs work.  Before choosing a plan, take the time to investigate each part and how it will affect your budget.

• Premium: this is the monthly amount you pay for your health insurance plan.
• Deductible: this is the amount you pay for covered medical care before your insurance starts paying.
• Copay: this is a flat fee that you pay each time you receive a health care service or procedure.
• Coinsurance: this is the percentage of the medical charge that you pay, the rest is covered by your health insurance plan.
• Out of Pocket Maximum: this is the most you’ll pay in one year, out of your own pocket, for covered healthcare. Once you reach this maximum, your insurance pays the rest.

Knowing exactly what is covered in your insurance plan and how much it will cost is sometimes difficult to find.  Be sure to check out the Plan’s Summary of Benefits and Evidence of Coverage – It should clearly lay out how much you’ll have to pay for services. These documents can sometimes be hard to find on the website, so utilize your customer service number on the back of your health insurance card for assistance in finding these documents.

Specific MS Health Coverage Needs

The items below are some important benefits to research regarding your health needs with MS. Utilizing the Evidence of Coverage document will give you a better understanding of what is covered and possible out-of-pocket costs to you.

• Specialized care: Neurologists, Physical Therapy, Mental Health support.
• In-Network vs Out-of- Network- review to make sure your MDs and facilities are in-network.
• Inpatient and Outpatient Hospital Care – what are the restrictions or costs?
• Dental and Vision Plan-are they included in your policy?
• Medications & Treatments:
  • Formulary– this is a list of prescription drugs covered by a prescription drug plan and how much you’ll pay for each.
  • Disease-Modifying Therapies– a drug or therapy that delays, slows or reverses the progression of a disease. Which ones are on formulary with your insurance plan? How much are you responsible for?
  • STEP Requirements- is a process by which insurers require patients to take one or more alternative medications before they can access the medicine prescribed by their provider.
  • DME or Durable Medical Equipment– supplies ordered by a health care provider for everyday or extended use such as: crutches, walker, wheelchair, cane, hospital bed, commodes, etc.
  • Deductibles– are there any deductibles for medications separate from healthcare deductibles?
  • • Frequency of care: estimate how many MD visits, lab tests, MRI scans you might have in the year and research if there are any limits or restrictions.
    • Expensive Treatments – how does insurer handle chronic condition care:
      • Prior authorization– is approval from a health plan that may be required before you get a service or fill a prescription to be covered by your plan.
      • Appeals– is a request for your health insurance company or Marketplace to review a decision that denies a benefit or payment. Do your research on how to appeal the claim with your insurance company.  Get your physician involved, in case they need to write a letter to justify the treatment plan.  Just because it was turned down doesn’t mean it won’t be paid. Be persistent!

Additional Services Available with Health Insurance

Many people do not know about the services available with their health insurance.  Do some research into the programs and services available within your policy.  Here are a few resources that may be available with your plan:

• Case Managers- can assist you in navigating all aspects of your healthcare benefits.
• Social Workers – can offer assistance with community resources.
• Wellness Support – may include coaches and programs for weight loss, exercise and smoking cessation.
• Dieticians- assist with special dietary needs.
• Second Opinion Benefits – confirm diagnosis and treatment plan with top MDs in the country.
• Benefit Advocacy Support – can help explain claims, billing questions, appeals.
• Employee Discount Benefits or Incentive Programs- some companies give out incentives for doing your annual physical, lab work, mammogram, colonoscopy, etc. Take advantage of these incentives.

Healthcare costs are always rising so here are a few things to review to make sure you’re getting the most out of your health coverage.

• Do you have money in an HSA (health saving account)- these are special plans, usually offered by an employer.
  • Money can be used for medical expenses.
  • You can roll over each year. You never lose this money, even if you quit or retire.
  • Good tax benefits on the HSA account.
• Use In Network providers and facilities to save money.
• Review of your bill and EOB (explanation of benefits)- is it correctly billed? If not, do some calling to provider or health plan for clarification.
• Do you need to appeal a claim-if justified treatment, appeal to get payment.
• Call to negotiate a new rate or set up a payment plan.
• Check into Pharmacy Discounts (Check Resources for MS page)
  • Mail Order
  • Good RX
  • Cost Plus
  • Needy Meds
  • Check Health Care Reform Drug List – some drugs are eligible for $0.
• Foundations for MS online for possible assistance. (Check Resources for MS page)
• Grant for MS online for possible assistance. (Check Resources for MS page)

Managing your health and finances is especially important when dealing with a condition like MS.  Be your strongest advocate by staying informed and utilizing all available resources to take control of your health journey.