Insurance coverage

Health insurance coverage for multiple sclerosis

Multiple sclerosis (MS) is a chronic disease that affects the central nervous system. There is no cure for MS, but there are many options for treating and managing this disease.

The average age at diagnosis is 32 years. MS affects everyone differently, with symptoms ranging from mild to disabling. Regardless of the degree of disability, managing MS across the lifespan can become a financial burden.

The National MS Society estimates that living with MS costs more than $70,000 per year per person. Of course, your experience may be different.

This article is about health insurance coverage and financial help for people with MS.

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Financial assistance for multiple sclerosis

The cost of your care can vary greatly depending on your health insurance coverage.

Health Insurance

Medicare is health insurance for people age 65 or older, but you may qualify sooner if you have a permanent disability from MS. Medicare is broken down into several parts as follows:

  • Part A covers inpatient care in a hospital or nursing home. It also covers certain home and hospice care. Most people don’t have to pay a monthly premium.
  • Part B covers visits to health care providers and other health professionals. It also covers durable medical equipment, outpatient services, and physiotherapy and occupational therapy. Most people pay a standard premium.
  • Part C is also known as Medicare Advantage. This is private insurance that provides benefits similar to Medicare.
  • Part D provides prescription drug coverage.
  • Medigap is supplemental insurance to Medicare. It pays certain reimbursable expenses.

Apply for health insurance

You may be automatically enrolled in Parts A and B if you have reached full retirement age or have been collecting Social Security Disability Insurance (SSDI) benefits for 24 months. The Medicare enrollment period is three months before and three months after the month you are eligible for full Social Security benefits. Medicare.gov provides a step by step guide to help you through the process.

Medical help

Medicaid is a federal and state health insurance program. It covers people with low incomes and people with disabilities. Eligibility requirements vary from state to state.

Apply for Medicaid

You can apply through your state’s Medicaid agency or through the Health Insurance Marketplace. Check your eligibility or find your state agency at Healthcare.gov.

Government assistance schemes

In the United States, nearly 30% of people with MS receive benefits through SSDI.

You must have worked in jobs covered by Social Security and be disabled. Multiple sclerosis is a qualifying disability when it involves:

  • “Disorganization of motor function in two extremities resulting in extreme limitation in the ability to rise from a seated position, to balance while standing or walking, or to use the upper limbs.”

WHERE

Marked limitation in physical functioning, and any of the following:

  • Understand, memorize or apply information; Where
  • Interact with others; Where
  • Concentrate, persevere or maintain the rhythm; Where
  • Adapt or Manage

Private insurance

Private health insurance is insurance that is not provided by a government agency. For example, insurance you get through an employer or insurance agent.

You can also compare plans and sign up through the health insurance market. Market plans should cover some key benefits. Plus, your income level may qualify you for tax benefits and premium savings. Certain life events allow you to register during a special registration period.

How to check if your MS treatment is covered

You need to check several factors to make sure your treatment is covered by your insurance, including finding a healthcare provider within your network and confirming that your insurance covers the services and medications you need.

Checking your health care provider

In most cases, you will want to find health care providers who are part of your policy network. This will help you reduce your personal expenses. Depending on your policy, you may have limited or no coverage when using out-of-network healthcare providers.

Your healthcare provider’s office may have a staff member dedicated to handling insurance. In many cases, they can work directly with your insurer to verify your benefits. You can call or log on to your insurer’s website to find in-network healthcare providers.

Checking your services

Call your insurer or see your plan’s Benefits and Coverage Summary page. It lists the services covered by your plan, as well as any copays or coinsurance.

Verification of your plan form

Your plan formulary is the list of drugs covered by your policy. It will also show your share. The formulary is divided into tiers for generic drugs, preferred brands, and specialty drugs. The higher the level, the higher the disbursement. You can usually find the form under the Summary of Benefits and Coverage for your plan.

Disease-modifying therapies (DMTs) for MS are considered specialty drugs. They tend to be among the most expensive on the form’s list.

Determination of total direct costs

Disbursements are those you must pay in addition to the monthly premiums. These fees include:

Health policies usually have an annual maximum payout. Once you reach the maximum, your policy covers 100% for the rest of the year.

Cost of MS treatment

DMT prices are the biggest expense associated with MS treatment. In the United States, many DMTs cost upwards of $90,000 per year. Your health insurance policy may cover some or all of these costs.

What to do if your treatment is not covered by your plan

Your healthcare provider may be able to direct you to resources. Pharmaceutical companies often have financial assistance programs for those who do not have adequate coverage. Be sure to check the manufacturer’s website for this information. Other organizations that may be helpful are:

Summary

Most insurance policies should cover part of your MS treatment. What you pay out of pocket depends on the details of your policy. You can avoid being caught off guard by checking your benefits before treatment.

If you don’t currently have health insurance, you may be able to sign up through the Health Insurance Marketplace. And most pharmaceutical companies have financial assistance programs to help cover the cost of DMT.

You can learn more about managing MS expenses from your health care provider’s office or by calling your insurer directly.

A word from Verywell

Living with a chronic illness is hard enough. And the financial reality of MS can be daunting. Fortunately, there are resources designed to help you navigate life with MS. Researching your options takes time, but could be worth it.

Whatever your concerns about MS, you are certainly not alone. You can find support and connect with others who are “getting it” through local chapter of the National MS Society.

Frequently Asked Questions

  • What benefits are available for people with MS?

    It depends on your particular situation. You may qualify for various health insurance options, prescription drug assistance programs, and other financial resources. To learn more about the potential benefits, contact the National MS Society. You can also consult the Grants and programs offered by the Multiple Sclerosis Foundation.

  • Is MS a pre-existing condition for insurance?

    Yes. But under the Affordable Care Act, Marketplace and Medicare plans must cover treatment for pre-existing conditions. And they can’t charge you more because you have MS. Grandfathered plans are an exception, but you can upgrade to a Marketplace plan during open enrollment.

  • Can people with multiple sclerosis benefit from Medicare?

    It depends. You are eligible if you are 65 or older. You may also be eligible if you are permanently disabled due to MS and have received SSDI benefits for 24 months.