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Navigating Insurance When Living with a Chronic Health Condition - Healthline

When you have a chronic health condition, managing your health can feel like a full-time job — and with insurance considerations thrown into the mix, that might switch to working overtime.

The complexity of health plan rules and codes, along with in-network and out-of-network providers and prescription coverage, can be dizzying. How can you navigate through it all, as well as calculate monthly expenses and save for emergencies?

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

Maybe you have a favorite doctor or specialist and you’re looking for a plan that ensures they’re in network. While that’s helpful, remember that your condition may require additional specialists, especially if it’s progressive. For that reason, it can be crucial to select a plan that either has a large medical network or covers out-of-network medical care at a reasonable rate, says Adrian Mak, CEO of AdvisorSmith, a business and consumer insurance firm.

Also, if you do expect to visit new specialists, he suggests choosing a preferred provider organization (PPO) plan that doesn’t require specialist referrals. This can cut down on doctor visits and related costs. By comparison, a health maintenance organization (HMO) plan might require you to see a primary care physician for a referral every time you need to visit a new specialist.

“The out-of-pocket maximum is another important consideration when comparing plans,” says Mak. “This number tells you the most that you’ll pay for in-network medical care during a calendar year when enrolled in a health insurance plan.”

If you have employer-sponsored coverage, you’ll likely be offered resources during open enrollment to help with decision making, says Brian Colburn, senior vice president of corporate development and strategy at Alegeus, a technology provider for administration of healthcare benefit accounts. Employers can be a rich source of info, yet he says many people don’t take advantage of the opportunity.

“We did a recent survey that showed workers are struggling to make the right benefit enrollment decisions, and 63 percent simply reenroll in the same plan as the prior year,” says Colburn. That can be true even if their health has changed, such as by receiving a chronic condition diagnosis.

If you don’t feel like your employer’s HR department is equipped to help or you don’t feel comfortable talking with that contact, he suggests asking for all the materials and taking time to go through them to make a more informed decision.

When calculating your expenses as part of the decision making process, it’s helpful to collect receipts for all healthcare-related expenses. 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 ongoing medical treatment needs when calculating expenses,” he suggests. “That means going beyond what your treatment entails and into what is being done to support your health overall.”

For example, that might mean expenses related to fitness, mental health, and healthy eating, he says. If you’re doing something to support your wellness, put it into the calculation.

In addition to (or instead of) an HSA, you may also have a flexible spending account (FSA). In general, the difference is that you control the allocations in an HSA and those funds roll over from year to year. Also, if you change jobs, you’ll keep your HSA money.

By contrast, an FSA is owned by an employer and usually has lower contribution limits, and the funds may expire at the end of the year. If you switch jobs, you’ll lose the FSA funds unless you continue your coverage through COBRA.

No matter which type of insurance you have, you can use these funds on out-of-pocket medical expenses not covered by insurance, says Colburn. That might include doctor visit copays, diagnostic tests, pharmacy items, prescriptions, vision care, and dental care.

“In an ideal world, you’d contribute the maximum amount to your HSA to pay for medical expenses, save money for future medical care, and invest to increase savings,” he adds. “Of course, ideal isn’t always reality. Many people can’t afford to engage in that way.”

He says the next best move is to contribute the dollar amount you think you’re likely to spend on out-of-pocket healthcare costs in the coming year, at least up to your plan’s deductible. That way, you can reach your deductible with tax-free dollars.

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

There’s a type of policy called chronic illness insurance, which pays a lump sum if you’re diagnosed with an illness that leaves you unable to perform at least two of the following six activities of daily living for at least 90 days: eating, bathing, getting dressed, toileting, transferring, and continence. You also usually qualify if you have a severe cognitive impairment.

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

If you already have a chronic condition, this may not apply to you. But if you’re concerned about being diagnosed with another illness on top of that, this kind of complementary coverage may be a fit — just be sure you know all the policy’s details before signing up, Chavez suggests.

In both employer offerings and your health insurance plan, dig deeper for perks and benefits related to wellness, Haney advises. These are often not widely promoted, but they can help optimize your health. For example, you could get a free or low-cost gym membership, take a healthy cooking class, talk with a weight loss counselor, or get telehealth sessions with a mental health therapist.

“Look beyond what insurance is providing for managing your diagnosed condition and into what you can do for your health overall,” he says. “Ultimately, we all must become our best advocates in taking care of ourselves physically as well as financially.”

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

  • Look for a plan that includes doctors and specialists you’re currently seeing. You can call the insurance provider to ask if a specific doctor is in network. Your doctor’s office can also tell you which insurance providers they work with and if they bill the insurance directly or if you’ll need to pay first and then have the insurance provider reimburse your expenses.
  • Add up the out-of-pocket maximum and the monthly premiums. This will help you understand the maximum amount you may expect to pay in a given year. In some cases, a plan with a higher out-of-pocket maximum may cost less in total than a plan with a lower out-of-pocket maximum if the monthly premium (the amount you pay into the plan each month) is significantly lower. It’s also important to pay attention to the deductible for office visits, specialists, and hospital stays.
  • Review covered services. 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 the drug coverage. Most insurance plans offer different coverage for generic versus brand-name medications. Review these differences, especially if you’re currently taking a brand-name drug.

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

It’s also important to confirm coverage before undergoing any expensive procedures, like an MRI. Even if the medical office verifies coverage, you can also call your insurance provider to confirm what’s covered and what’s not. That can help you avoid any unexpected bills.

Finally, contributing tax-free money to an HSA or FSA can help your dollar go a little further. Just remember that FSA dollars don’t roll over, so when contributing to an FSA, it’s important to think about how much you’re likely to need to spend out of pocket in the coming year.

Insurance can help save you thousands or, in some cases, hundreds of thousands of dollars in medical expenses. Get familiar with your plan’s coverage and medical network to help make the most of your plan.

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

Elizabeth Millard lives in Minnesota with her partner, Karla, and their menagerie of farm animals. Her work has appeared in a variety of publications, including SELF, Everyday Health, HealthCentral, Runner’s World, Prevention, Livestrong, Medscape, and many others. You can find her and way too many cat photos on her Instagram.