Orlando Harmon
Multiple sclerosis (MS) is an incurable, chronic inflammatory disease of the central nervous system that affects nearly 1 million people in the United States. With costly treatments, finding affordable health insurance with MS can be challenging. In the past, individual health insurance plans could charge people with pre-existing conditions like MS more for their insurance or even deny coverage entirely. However, since the passing of the Affordable Care Act (ACA) in 2014, insurers are no longer allowed to deny or limit coverage for people with MS. People with MS can also qualify for coverage under Medicare or Medicaid, depending on their age, income level, and ability to work. When choosing a plan, it is important to consider factors such as medication costs, long-term physical therapy needs, and whether inpatient, outpatient, or hospital care will be required.
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What You'll Learn
Individual health insurance plans
If you have multiple sclerosis (MS), it is important to consider your health insurance plan carefully. In the United States, most people qualify for private insurance through their employer when employed full-time. This insurance usually covers treatments associated with MS, but the specific amount of coverage will vary based on your plan. If you are not already covered by your employer, you can buy private insurance on HealthCare.gov, also known as the Health Insurance Marketplace.
The Health Insurance Marketplace offers different tiers of plans, with higher-level plans covering more but costing more each month. Platinum plans have the highest monthly premiums but cover almost everything, whereas bronze plans have the lowest monthly premiums and are designed for people who only need health insurance in emergencies. If you are on a regimen of MS drugs, you may need a higher-tier plan to avoid high out-of-pocket costs.
Each health insurance plan has a drug formulary, or a list of drugs it covers. Drugs are grouped into tiers, with Tier 1 usually including generic medications and Tier 4 containing specialty drugs, including those used to treat MS. The higher the tier of the drug you need, the more you may have to spend out-of-pocket. It is important to check whether the drugs you take are on the plan's formulary and to consider how much you would have to pay if your doctor prescribes a new drug not on the list.
In addition to medication costs, there are other factors to consider when choosing an individual health insurance plan. For example, if you require long-term physical or occupational therapy, or if you anticipate needing inpatient, outpatient, or hospital care, you should select a plan that covers these services. Most insurance plans will cover durable medical equipment (DME) such as wheelchairs to some extent, but it is worth checking before signing up.
Finally, it is important to consider your preferred doctors and hospitals when choosing a health insurance plan. Plans include certain doctors and hospitals in their network, and visiting healthcare providers outside of this network will cost more per visit. Therefore, you should look up your current doctors, specialists, and preferred hospital to ensure they are covered by the plan you choose.
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Platinum plans
The health plans offered under the Affordable Care Act (ACA) are categorized into different metal levels based on the cost and level of coverage offered. Platinum is the highest of the four health plan metallic levels under the ACA; the other three are Bronze, Silver, and Gold. While a Platinum health plan offers the lowest out-of-pocket costs when medical services are needed, it also has the highest monthly premiums.
During the open enrollment period for 2024 coverage, Platinum plans were only sold in the exchanges in 17 states, and enrollment in Platinum plans amounted to only 126,520 people nationwide. So, depending on where you live, you may be limited to a Gold plan as the most robust option if you don't qualify for cost-sharing reductions. It's important to note that Platinum plans have become much less common over time, and in most of the country, the available metal-level options are Bronze, Silver, and Gold plans.
If you qualify for a healthcare premium subsidy, you can use it to defray the costs of a Platinum health plan. The size of the subsidy is based on the cost of a Silver plan, but you can apply it toward purchasing a Platinum policy or a Bronze or Gold policy. However, subsidies are typically larger than normal from 2021 through 2025 due to the American Rescue Plan and Inflation Reduction Act. These enhanced subsidies will expire at the end of 2025 unless Congress acts to extend them.
If you are considering a Platinum plan, it is important to carefully review the plan details and consult with a healthcare insurance professional to ensure that it is the best option for your needs and budget.
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Basic bronze plans
If you have MS, you can get medical insurance through private insurance plans, Medicaid, or Medicare. Private insurance plans can be obtained through full-time employment or purchased at HealthCare.gov, also known as the Health Insurance Marketplace. The Marketplace offers four plan categories, or "metal levels," including Bronze, Silver, Gold, and Platinum.
However, bronze plans can still be a suitable option for individuals with MS depending on their healthcare needs and financial situation. For example, if you have a restricted budget and need to minimize your monthly healthcare expenses, a bronze plan's lower premium can help you save money. Additionally, all Marketplace plans, including bronze plans, must cover essential health benefits mandated by the Affordable Care Act (ACA). These benefits include outpatient care, mental health services, rehabilitative services and devices, and prescription drugs.
It is important to carefully review the details of the bronze plans offered in your state, as costs can vary depending on factors such as age, location, family size, and tobacco use. Additionally, consider your current doctors and specialists, as each plan includes certain in-network providers, and using out-of-network providers will cost more per visit.
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Medicare and Medicaid
Medicare is a federal program and a national health insurance program that primarily serves older people and those with permanent disabilities. Income and assets are not considered when determining eligibility for Medicare. People with Multiple Sclerosis (MS) can qualify for Medicare coverage before the age of 65 if Social Security determines that they are permanently disabled and they have received Social Security disability benefits for 24 months. Medicare beneficiaries with low incomes may be eligible for assistance with cost-sharing responsibilities.
Medicare works like other health insurance programs, paying a portion of the cost of certain necessary medical services. Original Medicare includes Parts A and B. Part B has a 20% coinsurance, i.e., the percentage of treatment costs that a beneficiary must self-fund. Medicare Part C, also known as Medicare Advantage, was introduced in 1997 and offers more kinds of benefit plans, including coordinated care plans, preferred provider organizations, medical savings accounts, and private fee-for-service plans.
Medicaid, on the other hand, is a federal and state program that provides medical assistance to eligible low-income populations. Income, age, family size, and situation are considered when determining eligibility for Medicaid. In some states, Medicaid programs pay for care directly, while others use private insurance companies to provide coverage.
Medicaid and the Children's Health Insurance Program (CHIP) provide free or low-cost health coverage to low-income people, families, children, pregnant women, the elderly, and people with disabilities. CHIP provides low-cost health coverage to children whose families earn too much to qualify for Medicaid. In some states, CHIP covers pregnant people.
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Travel insurance
If you have multiple sclerosis (MS), you can still get travel insurance, but it's important to find a specialist provider who can offer a policy tailored to your needs. Standard travel insurance policies often exclude pre-existing medical conditions, which can leave those with MS without adequate protection if they require medical treatment related to their condition while abroad. Therefore, it is essential to find the right specialist travel insurance.
When purchasing travel insurance, it is important to declare your MS and any other pre-existing medical conditions. This will ensure that you are covered in the event of a medical emergency related to your MS and avoid large medical bills if you need treatment in another country. Failure to disclose any pre-existing medical conditions may affect the validity of your policy. You can declare your medical history through an online medical screening process or over the phone, and this will help the insurer provide a quote that covers your specific needs.
Specialist MS travel insurance policies can provide cover for medical emergencies, trip cancellations, pre-departure medical issues, and other unforeseen events. They can also cover lost, stolen, or damaged personal belongings, including any medication you are taking with you, as well as travel delays, personal liability, and curtailment. You may also be able to add optional extras such as gadget cover, cruise cover, or winter sports cover, although this may increase your premium.
When travelling with MS, there are several other considerations to keep in mind. It is important to plan ahead when it comes to travelling with medication, as you may need to check how long a drug can be left out of the fridge or what the airline rules are about carrying syringes and medication. Carrying medication on a plane may require a letter from your doctor to confirm that you need it. It is also recommended to discuss any travel vaccinations with your GP or MS nurse, as there may be concerns about how these could interact with your condition. Finally, if you are not fully mobile, arranging assistance at the airport or train station can make a huge difference, and if you are easily fatigued, consider the placement of your accommodation to ensure it is accessible.
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Frequently asked questions
Yes, you can get medical insurance if you have MS. However, it can be more expensive and difficult to find the right insurance for your needs. People with MS can usually get life insurance, but it might be more expensive if you have more advanced MS. You may also qualify for coverage under Medicare or Medicaid, depending on your age and income level.
It's important to consider your specific needs and the costs of your current medications and treatments. If you are on a regimen of MS drugs, you may need a plan in a higher tier. You should also check if your current doctors and specialists are covered by the plan.
If you are unable to get medical insurance, you might be able to make a claim on policies you already hold. Check the small print to find out if your policy covers MS and under what circumstances it will pay out.
You can buy private insurance at HealthCare.gov, also known as the Health Insurance Marketplace. You can also call their toll-free helpline for assistance in reviewing your options.
