Navigate insurance when living with a chronic health problem


When you’re chronically ill, managing your health can feel like a full-time job – and with added insurance considerations, it could shift into overtime.

The complexity of health plan rules and codes, along with network and non-network providers and prescription coverage, can be staggering. How do you navigate all of this, calculate monthly expenses, and save in an emergency?

Here, some experts offer their best tips to streamline the process, so that you can spend more time on your health.

Maybe you have a favorite doctor or specialist and are looking for a plan that ensures they are networked. While this is helpful, keep in mind that your condition may require additional specialists, especially if it is progressive. For this reason, it can be crucial to choose a plan that has a large medical network or that covers off-grid medical care at a reasonable rate, says Adrian Mak, CEO of AdvisorSmith, an insurance company for businesses. and consumers.

Additionally, if you are planning to visit new specialists, he suggests choosing a Preferred Supplier Organization (PPO) plan that does not require specialist referrals. This can reduce doctor visits and associated costs. In comparison, a health maintenance organization plan (HMO) may require you to see a primary care physician for a referral whenever you need to see a new specialist.

“The maximum amount of spending is another important factor to consider when comparing plans,” says Mak. “This number tells you the maximum amount you will pay for network medical care in a calendar year when you are enrolled in a health insurance plan.”

If you have employer-sponsored coverage, you’ll likely be offered resources during open enrollment to help you make decisions, says Brian Colburn, senior vice president of corporate development and strategy. at Alegeus, a technology provider for the administration of healthcare benefit accounts. Employers can be a rich source of information, but he says a lot of people miss the opportunity.

“We did a recent survey that showed workers are struggling to make the right decisions to enroll in benefits, and 63% are simply re-enrolling in the same plan as the year before,” says Colburn. This may be true even if their state of health has changed, for example by being diagnosed with a chronic illness.

If you don’t think your employer’s human resources department is equipped to help you or if you don’t feel comfortable speaking with this contact, they suggest requesting all documents and taking the time to review them. browse to make a more informed decision.

When calculating your expenses as part of the decision-making process, it is helpful to collect receipts for all expenses related to health care. Even those you don’t pay through a health savings account (HSA) are important to consider, says Brian Haney, founder of financial services firm The Haney Company.

“Be honest about your current medical treatment needs when calculating expenses,” he suggests. “It means going beyond what your treatment involves and what is done to support your overall health.”

For example, it could mean spending on fitness, mental health, and healthy eating, he says. If you are doing something to support your well-being, put it in the math.

In addition to (or instead of) an HSA, you can also have a Flexible Spending Account (FSA). Usually the difference is that you control the allocations in an HSA and those funds are renewed from year to year. Plus, if you change jobs, you’ll keep your HSA money.

In contrast, an FSA is owned by an employer and typically has lower contribution limits, and funds can expire at the end of the year. If you change jobs, you will lose FSA funds unless you continue your coverage through COBRA.

No matter what type of insurance you have, you can use those funds for medical expenses not covered by insurance, Colburn explains. This can include fees for a doctor’s visit, diagnostic tests, drugstore items, prescriptions, vision care, and dental care.

“In an ideal world, you would contribute the maximum amount to your HSA to pay for medical bills, save money for future medical care, and invest to increase your savings,” he adds. “Of course, the ideal is not always the reality. A lot of people can’t afford to commit this way.

He says the next best thing to do is contribute whatever amount you think you’re likely to spend on health care costs over the next year, at least up to your plan’s deductible. This way, you can achieve your deductible with tax-free dollars.

“If you can’t afford to put on the maximum, don’t let that put you off putting on as much as you can,” suggests Colburn.

There is a type of policy called chronic illness insurance, which pays a lump sum if you are diagnosed with an illness that prevents you from performing at least two of the following six activities of daily living for at least 90 days: eat, take a bathing, dressing, going to the bathroom, transferring and continence. You are also generally eligible if you have severe cognitive impairment.

“Keep in mind that this insurance should not replace your basic health insurance – it is seen as a supplement to it,” says Linda Chavez, founder of Seniors Life Insurance Finder, an independent agency. “Also, it will pay off when the disease is diagnosed as a way to provide sufficient financial support so that your family’s needs are not compromised. “

If you already have a chronic illness, this may not apply to you. But if you’re worried about being diagnosed with another illness on top of that, this type of supplemental coverage may be fine – just make sure you know all of the policy details before signing up, suggests Chavez.

In employer listings and in your health insurance plan, dig deeper into the benefits and benefits of wellness, advises Haney. These are often not widely promoted, but they can help optimize your health. For example, you can get a free or low cost gym membership, take a healthy cooking class, speak with a weight loss counselor, or get telehealth sessions with a mental health therapist.

“Look beyond what insurance provides to manage your diagnosed illness and what you can do for your overall health,” he says. “At the end of the day, we all have to become our best advocates to take care of ourselves physically and financially.”

If you have a choice between plans, here are some tips that can help you find the plan that will best meet your needs:

  • Look for a plan that includes the doctors and specialists you are currently seeing. You can call the insurer to ask if a particular doctor is on the network. Your doctor’s office can also tell you which insurers they work with and whether they bill for insurance directly or whether you will need to pay first and then ask the insurer to reimburse your expenses.
  • Add the maximum amount and the monthly premiums. This will help you understand the maximum amount you can expect to pay in any given year. In some cases, a plan with a higher charge cap may cost less overall than a plan with a lower charge cap if the monthly premium (the amount you put into the plan each month) is significantly lower. It is also important to pay attention to the deductible for office visits, specialists and hospital stays.
  • Review the services covered. If you know you’re likely to need a specific treatment or procedure, find out what percentage of the service, if any, is covered.
  • Review drug coverage. Most insurance plans offer different coverage for generic drugs compared to brand name drugs. Review these differences, especially if you are currently taking a brand name medication.

Once you have a plan, it’s also important to regularly review your medical bills and insurance statements. If something is wrong or if you think you have been overcharged, it is worth taking the time to call your insurer or the medical office that submitted the claim. In some cases, a medical billing error could result in an additional cost.

It is also important to confirm coverage before undergoing expensive procedures, such as an MRI. Even if the doctor’s office verifies coverage, you can also call your insurer to confirm what is covered and what is not. It can help you avoid unexpected bills.

Finally, donating tax-free money to an HSA or FSA can help your money go a little further. Remember that FSA dollars are not renewed. Therefore, when you contribute to an FSA, it is important to think about how much you will likely have to shell out out of pocket over the coming year.

Insurance can help you save thousands or in some cases hundreds of thousands of dollars in medical bills. Familiarize yourself with your plan’s coverage and medical network to help you get the most from your plan.

And if you ever have questions about your coverage, call the number on the back of your insurance card to speak to a representative. They can help you explain all the nuances of your plan and answer any questions you have about medical bills or coverage.


Elisabeth millard lives in Minnesota with her partner, Karla, and their farm animal menagerie. His work has been published in various publications including SELF, Everyday Health, HealthCentral, Runner’s World, Prevention, Livestrong, Medscape and many more. You can find her and too many cat photos on her Instagram.





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