Insurance coverage

Health insurance for multiple sclerosis: coverage and cost

Multiple sclerosis (MS) is a disease that blocks the messages sent from the brain to the body. It can cause symptoms such as difficulty with movement, vision and thinking. Multiple sclerosis is a chronic and debilitating disease. Those affected must therefore find health insurance coverage, regardless of their income.

This article covers the types of insurance available for people with MS, financial assistance for MS patients, and things to consider when choosing a health insurance plan if you have MS. .

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Health insurance options for multiple sclerosis

Adults and children with pre-existing conditions or disabilities cannot be denied insurance coverage.If you can’t afford private insurance, your state might have Medicaid plans available. For others, private health insurance can help cover MS treatment costs.

Medical help

Medicaid is a state and federally funded low-income health insurance program. Some people are eligible for Medicaid after becoming too disabled to work, which can happen to those with severe symptoms of MS. Some Medicaid benefits are required by federal law, while others are optional and state dependent.

Federal Medicaid requirements include:

  • Screening and diagnostics
  • Disease treatment
  • Inpatient and outpatient care
  • Home care
  • Medical services

States can decide whether or not to cover the following:

  • orders
  • physical therapy
  • occupational therapy (therapy to help people with their daily activities)
  • Certain diagnostic and clinical services

Some states have not passed the Medicaid expansion that is part of the Affordable Care Act. This expansion allows people to qualify for Medicaid on income alone (below 138% of the poverty level). For states that have not adopted this expansion, disability, household size, and other factors are considered before approving Medicaid services.

Private insurance

If you don’t have health insurance through an employer, your spouse’s employer, or your parents (if you’re under 26), you may need to look to private insurance. HealthCare.gov, also known as Health Insurance Marketplace, is a great place to start your search. Insurance company websites and research can also be helpful.

When shopping in the health insurance market, it is important to determine if you qualify for a subsidy based on your income. This can provide some relief for more expensive plans, potentially saving you in the long run on out-of-pocket costs such as prescriptions, which tend to make up a large chunk of MS treatment expenses.

Applying for Health Care: How to Get Started

To view private or Medicaid care plans in your state and to start an application, you can visit HealthCare.gov or call 1-800-318-2596 (TTY: 1-855-889-4325).

If you need in-person help choosing a health plan that’s right for you, Health Insurance Marketplace provides local help via this search tool.

Other financial help for multiple sclerosis

There are several non-profit funds available to help people pay for MS treatment, including:

Choosing an insurance plan: things to consider

Some things to look for in a health insurance plan if you have MS include the following:

Service coverage

Service coverage is the type of services that an insurance plan will cover. There are services that all health care plans in the United States must cover, including:

  • Inpatient, outpatient and inpatient care
  • Emergency room visits
  • Prescription drugs
  • occupational therapy (helps people with their daily tasks, such as bathing or cooking)
  • Health screenings
  • Chronic disease treatments

It may be important for MS patients purchasing health care plans to consider additional costs such as:

  • Copays lab tests, such as those for MRIs
  • Specialist visits, such as physiotherapy sessions
  • Speech therapy
  • Cognitive rehabilitation therapy (to manage thinking problems)
  • Mobility aids, such as canes or wheelchairs
  • Hospitalizations
  • Future surgeries

Network doctors and specialists

Checking whether certain doctors, specialists, therapists and hospitals are part of an insurance network is an important part of choosing a health insurance plan for people with MS.

Additionally, it is important to check if a referral is needed to see a specialist or provider and how the referral process works.

Medication form

Drug formularies are lists of drugs covered by a health insurance plan. This can be found on the Health Insurance Marketplace website for individual plans.

Medications are often the most expensive part of MS treatment. For people with MS who wish to take out health insurance; it is important to consider the following:

  • The level of medication you are taking (generic versus brand name)
  • If there is a separate prescription quota
  • Prescription deductible (the amount you will need to pay before coverage takes effect)
  • Prescription out-of-pocket maximums (the maximum you have to pay yourself)
  • Procedures to follow when a medication is not on your plan
  • How infusion drugs (drugs given via an intravenous needle) are labeled (as a prescription or as a medical service) and how this affects costs
  • Are there any “step therapy” requirements (less effective drugs that patients must try before infusion drugs)

Reimbursable expenses

Out-of-pocket expenses may include premiums, co-payments, and anything else your insurance won’t cover. Higher tier plans, such as silver or gold tier plans, will have lower out-of-pocket fees and higher premiums.

Other costs that MS patients may consider include transportation costs, supplements, travel for treatment, special vehicles, food and daily care.

Summary

People with MS may develop problems with balance, thinking and planning, walking, muscle fatigue, vision and other aspects of daily living. Because MS is a lifelong disease that can get worse over time, it’s important that people with the disease choose the right health insurance plan. If cost is an issue, Medicaid plans and nonprofits can help.

Private plans can be purchased through the Health Insurance Marketplace (HealthCare.gov) or a private insurance company’s website. For those who cannot find full coverage through their health insurance plans, nonprofits can help fund diagnosis, treatment, travel, living expenses, and other parts of MS care. .

A word from Verywell

Although paying for multiple sclerosis treatment can seem daunting, help is available. Whether it’s through Medicaid, federal grants that cover health insurance costs, or nonprofit networks, you can get the treatment you need. The key is to advocate for your care, and given the cost of MS, it’s never a bad idea to ask a provider or organization how they can help you.

Navigating health care is a demanding task, but with a little help, the support system and health care you seek could provide you with the care you deserve.

Frequently Asked Questions

  • Is MS treatment covered by insurance?

    According to the Affordable Care Act, no one can be denied health insurance because of a pre-existing condition. Medicaid plans also cover MS treatments, although coverage may vary by state.

  • What financial help is available for people with MS?

    The Health Insurance Marketplace on HealthCare.gov provides income-based subsidies, which can help cover the cost of higher-tier plans that provide greater coverage. Medicaid can help low-income or disabled MS patients, while nonprofit grants can provide additional help. NeedyMeds, Patient Advocate Foundation, and the Multiple Sclerosis Association of America are just a few of the organizations that provide financial assistance for MS treatment.

  • Does MS prevent you from benefiting from life insurance?

    Younger, healthier people with MS are more likely to be approved for life insurance coverage. For one thing, because of advances in therapy and increased health insurance coverage, life insurance companies are more likely to cover MS than in the past. The more advanced your MS, the harder it can be to find a life insurance policy that fits your budget.

Verywell Health uses only high quality sources, including peer-reviewed studies, to support the facts in our articles. Read our editorial process to learn more about how we fact check and ensure our content is accurate, reliable and trustworthy.

By Neha Kashyap

Neha is a New York-based health journalist who has written for WebMD, ADDitude, HuffPost Life, and dailyRx News. Neha enjoys writing about mental health, elder care, innovative healthcare technologies, paying for healthcare, and simple steps we can all take to improve our health.