Health Insurance and MS: Breaking Down Benefits

12 Jun 2024 | ~26:58 Engagement Time


Stephanie Buxhoeveden , Nurse Practitioner & Judy Gulley , Nurse

Podcast Recording


Can Do Podcast Episode on Health Insurance with host Stephanie Buxhoeveden and nurse Judy Gulley

Join host Stephanie Buxhoeveden alongside nurse and certified case manager Judy Gulley as they explore the complexities of health insurance. From different insurance types to managing costs and benefits, it can all be confusing.  Nurse Judy breaks it all down and provides insights into which options might work best for you.  Stephanie also shares her own experiences navigating insurance while living with MS, providing real-life examples. Tune in for practical advice and valuable resources.

Nurse Judy refers to resources throughout the episode which can be found here: Episode Resources

Disclaimer: This podcast provides general educational information. Can Do MS does not endorse, promote, or recommend any product or service associated with the content of this program.


Health Insurance and MS: Breaking Down Benefits 

Episode 172 – Podcast Transcript  


Stephanie Buxhoeveden: Welcome to the Can Do MS podcast. I’m your host Stephanie Buxhoeveden. I live with MS and I’m also a clinician and MS researcher. Today we’re excited to welcome our guest, Judy Gulley, who’s a nurse and certified case manager, particularly adept at Navigating Health Insurance. Thanks so much for joining us today, Judy.

Judy Gulley: Thanks Stephanie for having me. I hope that I can help people with the crazy ways of health insurance.

Stephanie: Oh my gosh, yes. Because navigating health insurance is overwhelming, to say the least. So can you first start by telling us what kinds of insurance are available?

Judy: Well, there’s different types of health insurance available for, um, different situations. So if you’re employed, an employer-based insurance company, um, we’ll usually offer you some type of plan that you can, um, you know, join and also look at your spouse and partner’s plans. Sometimes you can join their plan as well. Look at both situations and see which one works best for you. There’s a COBRA plan, which is insurance coverage between jobs. Some coverage is, um, very expensive when you use COBRA and it is subsidized by your employer and usually there’s a limited time when you can get that COBRA and coverage. There’s market plan, which some people know as Obamacare or Affordable Care Act. It’s also called the exchange. This is insurance that you can get as an individual or through an employer who maybe has just 20 employees or less. If you’re a young adult under the age of 26, you can get your insurance possibly through your parents’ health insurance. If you’re in college, there might be a college health plan available to you as well. Now if you’ve been a veteran, there are VA benefits available through insurance. And Medicare of course, we think of that as for people who are 65 or older. But if you are on disability, you may qualify for Medicare. Now, Medicare has different sections which are original Medicare. They also have a supplement which adds some different benefits to your regular Medicare and Medicare advantage, which is a different broader section of Medicare and gives you a little bit more. And then also we’ve got Medicaid, and Medicaid is income based and also available to people who are on disability. And this is on a state by state basis. So you need to do a little research on that.

Stephanie: That’s an excellent overview. And I have personally dealt with losing health insurance coverage due to, you know, aging out of it or uh, losing a job or changing jobs. So I’ve had to use COBRA in the past. Can you tell me a little bit more about what somebody with MS should do if they have a qualifying event, right, like a firing or a marriage or how do you get healthcare coverage? Um, when something unexpected pops up in life.

Judy: Right? Because normally you can only join your plans once a year during that enrollment period. But if you have, you know, say a death of a spouse that you were insured by or you lose your job or can’t work, um, these are called qualifying events. That also includes, um, having a child, adopting a child, things of that sort. What you can do is if you’re employed, of course you can call your uh, resource department or human resource and tell them that you have a qualifying event and they will let you join the insurance, uh, plan. Um, same thing with marketplace and Medicare, all of them. It’s called, like I said, uh, qualifying event that you can join.

Stephanie: Awesome. I think that’s so important. People need to know that they can’t only join insurance at that certain time of year. So once you know what type of insurance and what company you’re gonna be working with, what should you look for in a plan?

Judy: Well, you definitely need to do your homework before looking at these plans. There’s probably three major factors to consider it that I’ll talk about. Um, types of plans, the costs, and also the benefits. So let’s first talk about the types of plans that usually are available. There are probably four or five different types of insurance plans, but the most common are HMO, which is a health maintenance organization and PPO, which is preferred provider organization. First off on HMO. The thing with HMO is it’ll cost you possibly a little bit less, but you’ll have a more restrictive group of physicians and providers you can go to. You have to have a primary physician as your, what I like to call a quarterback that will make all your referrals for you. So that’s a little limiting sometimes. Also, you cannot go out of network for any reason unless it’s an emergency, which is also a little bit restrictive. Copays may still apply, but again, you have to look at the costs. Now as a PPO or the preferred provider organization, that’s a tongue twister. Um, you can pay a little bit more, but you’re more flexible on who you use. You don’t have to have a primary physician. You can use whomever you want and you don’t need referral suggestions from your doctor. You can just call whomever you want as long as they’re in network, it’ll cost you less. You can go out of network but of course it’s gonna cost you a bit more. And those other two, they’re a little bit more one’s called exclusive provider organization and point of service plan. Those are very restrictive again and not as common. You don’t see those as much.

Stephanie: Yes, and I know for me, when I’ve been trying to pick between a plan that has both an HMO and a PPO option, I’ve gone onto the insurance website and you can actually look up who is and is not in network. So my neurologist is always my number one priority, making sure that that person is in network so I don’t have to change my neurology care. Um, and oftentimes the PPO for me has been the better way to go because it captures more of the specialists that I see. But that can be a consideration. That is something you can look up ahead of time to be prepared.

Judy: That’s right, that’s right. So next maybe let’s talk about cost for each plan. I think there’s five major parts of the cost segments of insurance that are important for you to learn. And that is premium. This is the monthly cost you’re gonna pay for your insurance. Your deductible, which sometimes people overlook is how much you’re going to pay in a year before your insurance kicks in and their costs in their payments, excuse me. Copay, this is a flat fee that you’ll pay each time you go and get a certain service. And let’s say for example, you’ve got a copay for doctor visits of $20. Every time you go to the doctor, it will be $20 out of pocket when you go co-Insurance is different. It’s a percentage of the medical charge that you pay. And how that works is normally it’s after you’ve paid your deductible, but it can vary with each plan. But um, it would be like an 80, 20 plan. So say you paid a thousand dollars for a hospital visit, the insurance company would pay 800 and you would pay 200. Out-of-pocket maximum is another one that’s very important to look at. This is the maximum you’ll pay out of pocket for the year and then insurance will kick in for the rest. And so you really need to make sure you check that. Now I say check your summary of benefits. That’s so important because when you’re looking at insurance plans, they’ll give you a very abbreviated amount that you’ll pay for like a doctor visit or for a hospital visit. But they don’t go into detail like maybe how much is a, uh, physical therapy visit or how much is it to go to emergency room? If you look up the summary of benefits, which you have to sometimes ask for, you can find that it’ll be clearly listed. So that’s important to look at. Lastly, maybe let’s talk about the benefits. Now I think that’s a really important part of it besides the costs and all that, but everyone should evaluate what benefits are important for your healthcare needs. What I think is important for me may not be the same for you. So I’m just gonna list a few that I think are important to look upfront. Ambulatory care, that’s anything you can walk into. Maybe a doctor office visit, an emergency room, an urgent care. Those are considered ambulatory. Inpatient, and a outpatient charges. Look at how much those are gonna cost you. Prescription drug coverage, super important especially for MS patients. You wanna know how much your medications are gonna cost you and where they fall in the tiers.

Now if you’re not familiar with prescription tier levels, that is, you know, usually starts at tier one being your least expensive, usually your generics moving up into your more expensive tier, maybe four or five, which are really infusion drugs and that type of thing. You’ll see where they fall and usually there’s a chart that’ll tell you what your copay is for that. Another thing to remember for prescriptions is do you have a deductible for your prescriptions or is it included in your medical deductions? Those are very important to look at so you don’t get surprised. And check for, especially for MS patients, if there’s any step requirements for your medications, do you have to try alternative medications before you can use the one that your physician really wants you to get on? And that should be laid out for you as well. Okay, moving off of prescriptions, maternity and newborn care. Are you in the age group where those things plus fertility benefits are important to you? See what’s offered for that plan. Mental health and substance use services, how much will you pay for lab? How about radiology? Not just regular X-rays, but advanced imaging like an MRI or a PET scan or CT scan. Those are all gonna be different labels for different copays. Uh, rehabilitation services, physical therapy, occupational therapy, speech therapy. Do you need durable medical equipment like walkers, canes, any kind of transportation help. And then some companies will offer dental benefits and vision. Those are usually an add-on, but some will include it. So that’s kind of the three that I think are really important. And um, what do you think, Stephanie? Any questions?

Stephanie: Yeah, absolutely so many questions. But I think some things that I’ve learned, you know, I was diagnosed 11 years ago and for the most part I can bank on needing two MRIs a year, a few blood draws, uh, three to five specialty care visits. Um, and certainly there have been years where I have been hospitalized or needed PT and my costs were higher. But for the most part, I think the first couple years I was sort of guessing at what plan would work the best and then I would use the prior year looking at my costs and how much I paid out of pocket to make decisions about, okay, is it time to go up to a more premium plan or can I do a lower deductible or a higher deductible? So I sort of use my previous year as the benchmark to see if there’s something I need to change in the upcoming years. And then I’ve also learned the trick of if you’re on an infusion or an expensive DMT, getting that infusion in January, having like the drug company pay for your copay and that counts and basically helped me meet my deductible within the first month of the year. And then from then on my care was a lot cheaper for the rest of the year. So things like that. Um, but on the flip side of that, if I know I’m gonna need an MRI in the winter, I try to get it done in December before the plan resets in January. So be cognizant of, you know, if you’re gonna have a high cost test or something going on, trying to get that in before the end of the year and your deductible resets can save you a lot of money after, after the holidays hit. Because nobody likes the big bills in January, I don’t think. Um, but yeah, just a few tips and tricks that I’ve found really make a difference in my bottom line.

Judy: That’s right.

Stephanie: While we’re on that topic, insurance can really eat into a household budget and it’s important to save as much money as possible. So do you have any tips for maximizing your insurance and helping to counterbalance those costs?

Judy: Right. Stephanie, you mentioned some really good ones, so if I’m repeating myself it, it might be that I think those are really great. So there’s probably about five important things to remember. Um, again what I just talked about, compare your prices on your plans with your premiums, deductibles, copays, co-insurance and maximum out of pocket, those are one. You mentioned the uh, policy, the same policy as the year before. Some people roll over their policy and say, you know what, I’m just gonna do what I did last year. And they don’t review it. My son is one of them who made that mistake. He came up with $2,000 more deductible this year than he was expecting and it’s because you know, he’s young, he just, oh, I’ll do what I did last year. You need to read it because the insurance companies will change their plans and it could be something deep in the copays that you don’t see that you may use like your MRIs or something. So make sure you do your research, calculate some medical costs like you said, how many times do I go get an MRI in a year? Do I see the specialist more than once? How many times am I going to my regular doctor? Am I staying in network where I can versus the out-of-network neurologist that I love, which certainly use them but know you’re gonna pay more. Um, you know, which medical services do you think you’re gonna need in the near future that maybe you didn’t have last year? So those are things to look at as well. Another option to look at for your plans is do they offer a high deductible plan, which includes a health savings account? Some companies will offer that and the savings account can be used for any healthcare needs or expenses, which is really important. I think one thing to look at if you’ve got an HSA plan is to at least try to save your deductibles.

That way they’re put aside, you don’t have to worry about them. They’re in a little pot savings that you can go to right off the bat. Health savings accounts can offer you some tax benefits, but you need to check with your tax preparation person, um, to see where, what your yearly maximums are and what kind of tax benefits you can get. The nice thing about NHSA is you never lose it. You can always keep it. If you retire or you leave your job, it’s still there for you. Another way to save for medical expenses is your flexible spending account, which is another employed benefit. And marketplace also offers those sometimes where you can put some money aside for a savings and sometimes your employer will also contribute to that and you can determine, you know, maybe how much my deductibles will be and I can use that money again, like I said, just like the HSA. The difference with the flexible spending account is that if you don’t use it in your policy year, you lose it. So you have to be real cognizant on how much you put in there to make sure that you have enough.

Stephanie: And some like over the counter medicines and other things could be covered by the FSA too.

Judy: True, true.

Stephanie: Are there other benefits offered by insurance companies that people with MS could take advantage of but might not know about?

Judy: Um, sure. Yeah, their insurance companies want you to be healthy because you know what? It saves them money. Not just your money but their money and they’re real cognizant of that. But if you’ve not ever used a case manager, call your insurance and see if they have one available to you. They can really help you navigate through the healthcare system anywhere from your disease process to helping you get to the people you need to for an appeal. Any of those things case manager is key for that. Social workers, some insurance companies do offer social workers as well as your hospital or large medical facilities, they also have social workers who can help you with local resources such as transportation, maybe meal service, maybe helping for caregiver assistance, um, wellness support. Um, a lot of um, companies will have coaches and support people with programs for weight loss, maybe, uh, quitting smoking, maybe an exercise program that you might need. So take advantage of those wellness coaches. Dieticians, what’s the first thing your doctor says? How is your diet? How are you eating? You know, we’re all a little bad about that, but having a dietician give you a plan is always helpful. And some insurance companies do offer a dietician consult for you. Second opinion benefits. A lot of people don’t have these, they’re very exclusive, but some employee benefit programs will offer a second opinion benefit. And what that is, is that consult for your physician with a physician who specializes in certain disease processes. They can really help you confirm a diagnosis, make sure that the treatment recommendations are where they should be and gives you and your doctor a little peace of mind. I always say two heads are better than one and don’t worry about your doctor being upset about it. They love to have a consult with a doctor[?].

So if you’ve got that benefit, for sure take advantage of it. There’s some benefit advocate supports, which are people who can help you with claims, billing appeals, that sort of thing. And your case manager can help you hook up with them. And also a really hidden part of benefits is an employee discount benefit. I worked, like I said, for a large healthcare insurance company and my colleagues did not even know about this. A lot of companies will give you a premium discount for getting your wellness checks, getting your lab work done, getting your mammogram or colonoscopy. My husband and I save $1,200 on our premium a year for just getting that done. They also sometimes offer gift cards. You know, maybe you’ll get a Panera gift card or something if you do your physical or you exercise so much in a month. These are things that you need to kind of dig in and look at. Health club organization discounts. Like if you go to a gym or a Y, they may also offer you a free uh, membership. And over the product credit, some Medicare companies will offer over the counter credit through their little pharmacies to buy band-aids or medications such as aspirin, Tylenol, that sort of thing. So those are just a few things just to kind of sum up what’s going on.

Stephanie Yeah, and you’re paying all this money, you might as well use every single benefit you can get. Right? Right?

Judy: Absolutely. I say that all the time.

Stephanie: Uh, so you know, as we’ve already touched on, these costs add up quickly, especially at the beginning of the year when you have a deductible to meet. So what are some ways you can save on the cost that you are responsible for?

Judy: Right? You really, again, need to do your homework, but if you do, you can save yourself thousands of dollars. So again, talking about HSA, do you have some money in your HSA that you’ve got for your deductible expenses? That would be one thing. Are you using all the in-network providers that you can to help keep those costs down? Are you reviewing your bills or your explanation of benefits? Sometimes we call that an EOB that you get in the mail or online. Make sure that that service that’s listed is really what you had done. Mistakes get made all the time. So make sure it’s correctly billed. Do you need to appeal a claim? Maybe you see something on there that isn’t right. The billing service says it is. You can appeal some of those claims. And I’ve offered Stephanie a link to, um, a nice area where you can get some of those healthcare appeals, how to do them, where to go. Um, also check to negotiate if you can, maybe you got a bill and you just don’t have the money in your HSA or in your savings account. Ask them, is there a way that we could set up a payment plan or if I pay cash, can you give me a new rate? They do not wanna send you to a collection bureau because they lose 50% of their money so they’re happy to get some money versus less. So see if you can work out some kind of plan with them. Check into pharmacy discounts. I’ve also sent Stephanie some links for different discount rates that you can get on pharmacy, but just to name a few. GoodRx might be one, cost plus, which is Mark Cuban’s new company even has some MS drugs on there. Needy meds. Um, check into your mail order service for your pharmacy.

Sometimes you can save big bucks by doing that, plus it gets delivered to your home. And I know MS drugs usually have to come from a specialty pharmacy, but you know, are you on a low cholesterol drug? Are you diabetic? These are things that you can look at and see if you can save a little bit money. Also, one thing that some people don’t realize is the um, affordable Care Act added a $0 healthcare reform bill for some drugs. Make sure you look into that. It could be the statins or the ones that you use for your cholesterol. It can be um, breast cancer, excuse me, and HIV prevention medications, contraceptive medications. If you’re on Metformin for your diabetes, some of the companies will give you those for $0 and that will save you a lot. There’s a lot of foundations and grants available to MS patients, but you need to get on those right away first thing in the beginning of the year because that money is only limited and they can only give out so much. I’ve also given Stephanie some links for those too. Um, there’s free resources for MS patients and again, there’s a link and the resources for that. But a lot of um, groups are helping MS patients, for example, Can Do MS. Great organization. They have great websites on there and podcasts for you to listen to that will help you with your health. So those are some of the things to sum up what you need by basically doing your homework, know your plans, compare your costs and benefits. Remember, this is your health. Unfortunately, it’s a little bit of homework and a lot of research, but it’s worth your money. Take charge of it, ask questions and for sure ask Nurse Judy on Instagram and Facebook.

Stephanie: Perfect. Wonderful. I love all of those resources and I really encourage everybody to cruise them because you know, for instance, there are grants and funds to help you get free MRIs or medical equipment, even laptops. And if you save a hundred bucks there, you can apply it towards something else that you also need. So any little trick. And I love GoodRx because I myself was shocked when I first started using it for my medications, how different the cost of the drugs that I take every day, you know, on like seven different things for MS and for symptom management. And it makes a huge difference whether you get it filled at Wegmans or CVS or Walgreens or Walmart. They can sometimes be double the price at one pharmacy versus the other. So I love that GoodRx will tell you which pharmacy is the lowest and they give you coupon and that has saved me so much money.

Judy: Right, right. They are great coupon companies

Stephanie: Yes. Right. So thank you so much Judy for joining us, for sharing your knowledge and your perspective. I learned a lot. I’m sure our listeners learned a lot and it’s a really hard topic and we can’t thank you enough for just helping us break it all down.

Judy: Thanks for having me. I appreciate it.

Stephanie: In the description of this podcast, you can find resources, programs, and more information on what we’ve talked about here today. Thank you for listening to this episode and if you enjoyed what you heard, please leave us a rating and review on Apple Podcasts or Spotify. We really appreciate your feedback. Lastly, we’d like to thank all of our generous supporters for their support of this episode of the Can Do MS podcast. We couldn’t do it without them. Until next time, be well and have a great day.


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