Job-based health insurance includes various health insurance plans offered as a benefit of employment. Also known as employer-based insurance or group coverage, this insurance is given to employees by their employers or unions. If you have multiple sclerosis (MS) and work at a company with more than 50 employees, your employer likely will offer you some form of health insurance coverage. You may also have access to employer-based insurance at smaller companies.
If you have MS and do not have a job or your company doesn’t offer health insurance, job-based health insurance may still be available to you through your spouse or parent (up to age 26). Although job-based health insurance plans vary by company and may fluctuate with the economy, understanding your insurance options will help you to find the best plan to help cover health care costs for treating your MS.
Job-based health insurance plans vary by employers, and health benefits depend on the agreements made between employers and health insurance companies. There are several common types of health insurance policies offered by employers.
Health maintenance organization (HMO) plans are health insurance plans that operate within a network. Under an HMO plan, only specific doctors, facilities, and services will be covered. If you go out of the network for care — such as emergency services or urgent care outside of the HMO’s operating area — the health plan may not cover the associated costs. In these cases, you will have to pay out of pocket. An HMO plan may only be available to you if you live and work within the network’s area of coverage.
With HMO plans, you usually have to pick a primary physician within that plan’s network. To see a specialist, such as a neurologist, you will need to first visit your primary physician and get a referral from them. HMOs usually cover prescription drugs, but you should review the formulary (or list of drugs) that they cover.
Like HMO plans, preferred provider organization (PPO) plans offer care within a network of hospitals and physicians. You will pay higher costs if you receive care from a provider that is outside of that PPO’s network.
Unlike an HMO plan, you do not need to select a primary care physician within a PPO plan’s network. You can usually keep the primary physician you already have. You also will not need to get a referral from a primary care physician (PCP) before seeing a specialist.
PPO plans, in general, are more flexible than HMO plans in that you may receive care from health care providers that are either in or out of the plan’s network. While PPOs are more flexible, they may cost more than HMO plans. You should factor higher monthly premiums, copays for doctors' visits, and annual deductibles into your decision-making process.
Sometimes employers offer point of service (POS) health plans, which cover care within a network of hospitals and physicians. You may still receive care outside of the plan’s network, but costs will be higher.
Like with an HMO plan, you will initially need to select a primary care physician within a POS plan. This PCP will also help to manage your care and provide referrals to specialists from within the plan’s network. POS plans may cost less, but if you select this type of plan, you may need to change your health care providers and work through a PCP to manage your MS.
If you have MS and are selecting a job-based health insurance plan, you will want to check that a health plan covers:
You should enroll in a job-based health insurance plan as soon as possible after employment begins or during open enrollment. Your employer’s human resources department should be able to assist you with reviewing and selecting the best health plan for your needs.
The cost of job-based health insurance will vary by the types of health plans available through the providing employer or union. The cost of the plan will sometimes be inversely related to the plan’s flexibility. For example, an HMO plan may cost less, but it also may offer a limited pool of doctors to choose from.
With job-based health insurance plans — like other insurance plans — you will have to pay a monthly premium. However, your employer will subsidize a portion of that monthly cost — or perhaps all of it. You will be responsible for a portion of the costs for hospitalizations, surgeries, emergency care, copays for doctor’s visits, and medications.
With job-based health care, people with MS will usually put the most costs toward:
The National Multiple Sclerosis Society offers several tips for keeping costs down while on a job-based health insurance plan:
If you need additional assistance with paying out-of-pocket costs for treating your MS, the National Multiple Sclerosis Society provides a list of patient-assistance programs, which offer financial assistance based on the MS medication you are taking. Review this list to see if you may qualify for additional financial assistance.
If you have a job-based health insurance plan and need additional financial support to cover the expenses of treating your MS, you may seek assistance for copays and premium costs through a charitable organization called The Assistance Fund. Eligibility is based on your current insurance and income, and you can learn more and enroll in their programs on their website.
If your job-based health insurance plan ends — whether you lose your job, decide to leave, or retire — you have several other options for health insurance.
MyMSTeam is the social network for people with multiple sclerosis and their loved ones. On MyMSTeam, more than 167,000 members come together to ask questions, give advice, and share their stories with others who understand life with multiple sclerosis.
Do you have MS and use job-based health insurance? Share your experience in the comments below, or start a conversation by posting on your Activities page.