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Individual Health Insurance for People With Multiple Sclerosis

Medically reviewed by Amit M. Shelat, D.O.
Posted on April 12, 2021

How To Enroll | What Does It Cover? | Cost | Help | Support

Multiple sclerosis (MS) can be a challenging disease to navigate. The condition is chronic, progressive, and sometimes unpredictable, and the various medications and treatments to maintain a good quality of life can be costly. Total health care costs can range from $8,500 to upwards of $50,000 annually, according to a study from the Journal of Medical Economics. With such costly treatment, it is important to review your options for health insurance.

Some people with MS go with individual insurance plans, which are for individuals who are:

  • Self-employed
  • Ineligible for employer-covered health insurance plans
  • Ineligible for Medicare (for which you must be at least 65 or disabled) or Medicaid (for which you must have low income)

In the past, individual health insurance plans could charge people with preexisting conditions like MS more for their insurance, or they could deny coverage entirely. However, with the passing of the Affordable Care Act (ACA), as of January 2014, insurers are not allowed to deny or limit coverage for people with existing conditions like MS.

If you have MS and are not eligible for employer-covered health insurance, Medicare, or Medicaid, then individual health insurance may help you cover the health care costs of your MS. Notably, multiple sclerosis is recognized by the Social Security Administration as a disability that could qualify you for federal benefits like Social Security Disability Income and Supplemental Security Income — though each program has other criteria you must meet.

How Do I Enroll in Individual Health Insurance?

Per the ACA, you may enroll in individual health insurance through the health insurance marketplace at HealthCare.gov. About 15 states have their own state exchanges through which you can apply for individual health insurance. Additionally, you may apply through insurance companies that offer individual health insurance, or you can go through a state-licensed insurance broker or agent.

Enrollment Windows

When considering enrollment in individual health insurance, you must enroll during a specified enrollment window. There are two enrollment windows. One is the Open Enrollment Period, which is usually from Nov. 1 through Dec. 15, with coverage starting Jan. 1. However, because of the current COVID-19 public health emergency, open enrollment for 2021 is available from Feb. 15 and May 15.

Second is the Special Enrollment Period, which spans a window of time (usually 60 days) after you have experienced a major life event, sometimes called a qualifying event. Qualifying life events include:

  • Losing a job
  • Moving to a new state
  • Getting married
  • Having a baby

You must re-enroll in your individual health insurance plan every year. If you are currently enrolled in an individual plan, your provider will contact you every fall to re-enroll for the coming year. You have the option to re-enroll or switch plans during the aforementioned open enrollment window.

What Does Individual Health Insurance Cover for MS?

Therapies, treatments, and medications for MS may be covered differently under different individual insurance plans. According to the Affordable Care Act, most individual insurance policies must provide coverage for 10 essential services. The essential health benefits specific to MS include the following:

  • Ambulatory patient services (care you get in a medical facility that is not a hospital)
  • Emergency services
  • Hospitalizations, like surgeries and overnight stays
  • Services for mental health and substance use disorders, including counseling and psychotherapy
  • Prescription medications
  • Rehabilitative and habilitative services and devices, like canes, walkers, and wheelchairs
  • Laboratory services, including tests
  • Preventive and wellness services and chronic disease management services, like screenings for different diseases and immunization vaccines

Researching Plan Coverage

When considering enrolling in an individual health insurance plan, it’s important that you take the time to research several key details. Look for these items:

  • Health and medical services covered — These can include inpatient and outpatient services. You will want to take into account your current and anticipated needs.
  • Health care providers included in the plan — Be sure to check that your primary physician and other key members of your health care team are included in the plan.
  • Drugs covered — Each plan has something called a formulary, which is a list of prescription drugs the plan will help pay for.

The National Multiple Sclerosis Society offers an application checklist to help you consider an individual health insurance plan.

What’s the Cost of an Individual Insurance Plan?

The cost of individual insurance plans will vary based on the specific plan, as well as your location, coverage requirements, and needs. Individual plan costs are based on an income scale. Each month, you will need to pay a premium for the insurance plan. Monthly premiums and the amount of coverage varies by plan. Plans usually include a range of what are called bronze, silver, gold, and platinum plans, with bronze having the lowest monthly premiums and platinum having the highest.

Other costs to consider when shopping for an individual insurance plan include copays for doctor visits (e.g., an office visit with your primary care physician or neurologist), and deductibles, the minimum cost you must pay before your plan will kick in with its cost-sharing benefits.

If you’re having trouble affording your insurance plan, you may be able to use one of several savings programs. You can find out if you’re eligible for savings by filling out an application at HealthCare.gov. If you have a limited income, you may find that your state’s Medicaid program is a better option, as it could offer coverage at a lower monthly cost.

Additionally, extra coverage may be available if you’ve undergone any recent hardships such as:

  • Being homeless
  • Facing eviction
  • Filing for bankruptcy
  • Being a victim of domestic abuse

You can find the application and review your eligibility on the hardship exemptions section of the HealthCare.gov website.

Help With Individual Insurance

If you would like assistance in reviewing your options for an individual health insurance plan, HealthCare.gov offers a toll-free help line at 800-318-2596. You could also learn more about the marketplace at HealthCare.gov or your state exchange's website, or by using this tool to find help from an insurance agent or broker near you.

Talking With Others Who Understand

MyMSTeam is the social network for people with multiple sclerosis and their loved ones. On MyMSTeam, more than 166,000 members come together to ask questions, give advice, and share their stories with others who understand life with multiple sclerosis.

Are you living with MS and using individual insurance? Share your experience in the comments below, or start a conversation by posting on your Activities page.

Posted on April 12, 2021
All updates must be accompanied by text or a picture.

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Amit M. Shelat, D.O. is a fellow of the American Academy of Neurology and the American College of Physicians. Review provided by VeriMed Healthcare Network. Learn more about him here
Elizabeth Wartella, M.P.H. is an Associate Editor at MyHealthTeam. She holds a Master's in Public Health from Columbia University and is passionate about spreading accurate, evidence-based health information. Learn more about her here

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