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:
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.
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.
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:
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.
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:
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:
The National Multiple Sclerosis Society offers an application checklist to help you consider an individual health 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:
You can find the application and review your eligibility on the hardship exemptions section of the HealthCare.gov website.
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.
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.
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