For some, choosing a health insurance plan is pretty simple. But for those with a chronic condition, trying to find the right insurance coverage to treat their disease without going broke is a chore. And when that chronic condition is an autoimmune disorder, it’s a whole different ballgame.
This class of diseases, characterized by the immune system’s attack on healthy tissues within the body, is incredibly expensive to treat. And because no autoimmune disorder is curable, they usually come with a lifetime of medical expenses.
Patients with certain autoimmune disorders such as rheumatoid arthritis, lupus, type I diabetes, and multiple sclerosis are at higher risk of developing additional disorders. This only increases costs, sometimes doubling drug and specialist expenses as each disorder requires different treatments.
These high costs make it essential that you have the right health insurance. Here are the factors you need to consider to make sure you have the proper coverage for your condition:
(1) Find the Best Insurance Network for You
The healthiest individuals may only need a primary care physician, but a person with autoimmune disorders may need an entire team of specialists. If you have multiple care providers and you’d like to keep them, your first step should be calling to ask which health insurance plans they take. This way, you can narrow your search to the plans that cover all of your specialists, primary care doctor, and the hospitals where they practice.
If your diagnosis is new or you’ve recently moved, you’ll probably have to find a new team of care providers. When starting to compare insurance providers, it’s crucial that you look at how many different types of care are covered, including quality primary care physicians, clinics, urgent care, specialty clinics and a network of specialists.
The takeaway: The group of providers an insurance plan will definitely cover – known as an insurance network – is key to saving money on healthcare and simplifying your treatment plan. Someone with an autoimmune disorder may need multiple visits to the doctor each year, and paying out of pocket every time can get very expensive very fast.
(2) Join Assistance Programs for Affordable Medication
One of the most common types of treatment for many autoimmune disorders is with costly biologic medicines. They are the product of using biotechnology to create medicines from living cells, and they can cost thousands of dollars each month.
As a result, people who need biologics can meet their deductibles (the amount the patient must pay out-of-pocket before the insurer starts covering a larger percentage of costs) at the beginning of the year, says Jennifer Gentilcore, a multiple sclerosis patient and medical assistant in Windsor, Colorado. As part of her job, she works as a liaison between patients and insurers, helping other MS patients schedule exams and obtain prior authorization.
“I met my deductible every year in January,” says Gentilcore, who used to take an intravenous biologic that treats both MS and Crohn’s disease. The company that made her biologic paid her deductible as part of a patient-assistance program. “It was $3,000 for one infusion, and that was my deductible,” she adds.
She now takes a different medication, also a biologic, and the assistance program pays for her drug co-pay each month. “If you can get into an assistance program for your drug, it’s definitely something to think about when looking for insurance,” Gentilcore says. Most biologics have a patient-assistance program.
The takeaway: Switching drugs is common; autoimmune disorder patients often have to try several expensive drugs before finding one that works and is tolerable. If you take a costly drug for your disorder, check to see if you qualify for an assistance program before purchasing insurance. Then, purchase an insurance plan that does cover your drug, if possible. If you’re not sure, call the health insurance customer service line to check.
(3) Schedule Ahead for Annual Imaging Exams
Many autoimmune disorder patients also need annual imaging exams, but CT scans and other imaging exams can cost thousands, even with insurance. And after Gentilcore’s deductible was met in January, she wasn’t quite off the hook for her health expenses: She still had to meet her out-of-pocket limit (the amount the patient must pay before the insurer will fully cover all in-network costs).
Gentilcore needs three MRIs annually: one each of the brain, neck, and lower spinal cord. Being mindful of her insurance coverage helped Gentilcore come up with a cost-effective plan so she could receive the exams she needed without going into the red. “My doctor and I worked it out so I take those at the end of the year, once my out-of-pocket maximum is met,” she says, so that her insurance covers the full cost of the expensive imaging exams.
The takeaway: Plan out your medical expenses, including doctors’ appointments and exams for the year.
With any health plan you’re considering, compare the premium to your estimated out-of-pocket expenses. Is it cheaper to pay higher premiums all year and have lower out-of-pocket expenses, or the other way around? Because these autoimmune disorders are as diverse as the patients they affect, it’s important to analyze your particular situation.