MS and health insurance

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Health insurance coverage is important for anyone but especially so for someone who has MS. In some countries, such as Canada, the United Kingdom, and Germany, patients access medical care through the country’s national health system. In countries with a national health system, care is financed (paid for) primarily by the government. In the United States, healthcare is financed through a complicated system of health insurance and government coverage options. The remainder of this section will focus on health care access and the health insurance marketplace in the United States.

Every person should have health insurance and reliable access to health care. Over his lifetime, a person diagnosed with MS will rely upon healthcare to provide medical care, prescription drugs, rehabilitation services, and allied health needs. Health insurance that includes hospitalization, major medical coverage, and generous prescription coverage is essential for a person diagnosed with a condition such as MS which is associated with considerable costs.

Be informed about your health insurance options to protect your financial future and access to health services. A basic understanding of key concepts and terms will help you to navigate your insurance options.

 

Fee-for-service versus managed care

In the traditional fee-for-service system, hospitals and doctors set the price for services and receive payment for each and every service provided.  Policy holders are free to choose any doctor or hospital, however insurance may limit the amount they will cover and the patient must pay the difference. Fee-for-service is blamed for contributing to the rising costs of health care in the US. There are two types of fee-for-service health insurance plans: indemnity and reimbursement. In an indemnity plan, the insurer agrees to play an amount for specific medical services.  Any cost beyond this stated limit must be paid by the patient.  With reimbursement plans, the policy holder pays upfront for all care and must file records with the insurance company for reimbursement.  It is important for policy holders to be familiar with the specific terms of their policy in order to maximize their insurance coverage  One element of fee-for-service plans which appeals to consumers is that they allow you to choose your own provider.

Managed care health plans were created in an attempt to control healthcare costs. With managed care plans, the insurance company contracts with specific health providers (doctors, hospitals, pharmacies, etc) to provide services to policy holders. People with managed care plans pay less for care obtained within the contracted network of providers. The three most common types of managed care plans are health maintenance organizations, preferred provider organizations, and point of services plans.

Health maintenance organizations (HMOs) provide a one-stop-shopping approach to healthcare where all services are provided within a single network. In HMOs, patients need referrals from their primary care physician (PCP) to see specialists, such as a neurologist. Policy holders are limited to providers and services available within the network, but out-of-pocket costs include predictable co-payments and lower premiums on average

Preferred provider organizations (PPOs) provide another lower cost option for obtaining care through a network of providers who have contracted with the health insurance company to offer discounted rates to policy holders. Patients are able to choose any health care provider, including specialists, without a referral.  However, if they choose to receive care out-of-network, then they must pay for a larger portion of the costs.

Some health insurance companies offer a point of service (POS) plan which takes a hybrid approach combining elements of FFS, HMO, and PPO plans.  With POS, policy holders can choose who to see each time there is a need for medical care and are not limited to a specific network. For example, the policy holder can choose a primary care doctor at an HMO with a small copay, see a neurologist who is a PPO provider and agrees to accept discounted rates, or go outside of any network at a higher out-of-pocket cost.

In today’s health insurance market, managed care plans are much more popular and fee-for-service plans are rare. Interestingly, one example of a pure fee-for-service plan is Medicare.

 

How do I know what I’m eligible for?

Previously, eligibility rules for health insurance plans were based on certain eligibility criteria or rules that spelled out who qualified for a specific plan. With the 2010 Patient Protection and Affordable Care Act (ACA), eligibility rules will undergo significant changes as reforms are gradually adopted over the next few years. In the US, a person can get health insurance either through the government or through a private insurance company. The tables below outline basic information regarding insurance coverage eligibility, organized by the type of government or private plan.

Eligibility requirements for government-provided insurance coverage vary by program. Government insurance programs include Medicare, Medicaid, Veterans’ benefits, TRICARE, Federal Employee Health Benefits Program (FEHB), State Child Health Insurance Programs (S-CHIP), and insurance programs for employees of state and local governments. To qualify for government coverage, a person must:

  • Qualify for a government entitlement program such as Medicare or Medicaid;
  • Be employed (currently or previously) by a federal agency or the military; or
  • Be a family member or dependent of someone who works/worked for a government agency and qualified for such an insurance program

Many types of private health insurance plans are available, including group coverage as a benefit of employment or membership in a union or other organization, individual plans available to self-employed persons or to individuals and families outside of employment, high-risk health insurance pools to cover those who are otherwise uninsurable, and Medicare supplemental insurance sometimes referred to as Medigap.

Government Insurance Programs

Medicare
Source of coverage for most people 65 years or older
Medicare Parts A, B, C, and D, there are several options available for organizing and accessing care, including prescriptions, sit is important tget advice about Medicare options if you are eligible
People younger than 65 years who are disabled (including those with MS) may qualify*
Medicaid
Medical assistance entitlement program for people and families with low income, with benefits varying from state tstate
Provides coverage for a variety of long-term care services, including stays in nursing homes
ACA reforms may expand eligibility
S-CHIP
Coverage for children in families that do not qualify for Medicaid
VA Benefits
Comprehensive healthcare for veterans with service-related disabilities
MS may be considered service-related under certain conditions
TRICARE
Health benefit program for active duty and family, reserves (under certain conditions), retired military and family
Offers both fee-for-service and managed care plans
FEHB
Choice of health plans for federal, non-military employees and eligible family members
Available from date of enrollment without restrictions
May continue (under certain conditions) for employee and/or eligible family members beyond retirement and death of employee
State and local government employee plans
Health benefit plans for employees and eligible family members

*Must meet Social Security Disability Insurance or SSDI criteria. A 24-month waiting period is required before coverage begins.
Source: Calder K. Managing the insurance maze. In: Kalb R, ed. Multiple Sclerosis: The Questions You Have – The Answers You Need. 5th ed. New York, NY: Demos Health; 2012:317-333.

 

Private Health Insurance

Group health plans
Offered temployees and often tfamily members
Choice of different plans typically offered
ACA offers employers an incentive tprovide insurance temployees and penalizes large employers whdnot
Can be either fully insured or self insured*
Individual and family plans
Purchased by individuals tcover themselves and their families
With ACA, these types of plans cannot be denied tsomeone on the basis of a pre-existing condition and must be made affordable
Medigap
Supplemental insurance that can be purchased tpay costs not covered by Medicare
State high-risk pools
Coverage for state residents whare uncoverable due ta pre-existing condition
Will be discontinued over time as ACA is phased-in and provides coverage for all patients with pre-existing conditions
COBRA
Temporary extension of coverage for people whlose employment-group health coverage through loss of employment, divorce, retirement, death of spouse, disability, or Medicare enrollment of spouse

COBRA refers tthe health benefit provisions from the Consolidated Omnibus Budget Reconciliation Act of 1985.

*It is important to find out which type applies to you and what it means for your coverage. Unlike fully insured plans, self insured plans are not regulated on a state level and this may affect you if there is a dispute concerning your legal rights as member of the plan.

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