How to buy a health plan when you have a chronic medical condition

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‘Tis the season for health insurance, whether you’re buying a plan through your employer, through a government-run marketplace in your state or directly from a health insurance company on your own.

Thanks to the Affordable Care Act, you can no longer be denied health insurance because you have a pre-existing condition. But that doesn’t mean your choice of health plan gets any easier. If anything, having a chronic condition makes a purchase decision more difficult.

According to the Partnership to Fight Chronic Disease, more than 133 million Americans — about 45 percent of the population — has at least one ongoing or chronic condition such as heart disease, cancer, diabetes or asthma.

Your health insurance decisions are the same whether or not you have a pre-existing condition, says Craig Rosenberg, health and wellness practice leader for Aon Hewitt, a human resources solutions firm. Everyone has to look at coverage levels, premiums, deductibles and other out-of-pocket expenses. “But your choices become even more important simply due to the fact that you’re likely to use more health care than someone who is healthy,” he says.

Start the health insurance decision with your doctors

A good place to start is with your health care providers. Before you sign up for a health plan, talk to your health care providers about what the coming year might look like for you, advises Glenda Terry, a registered nurse on Aon Hewitt’s advocacy team. Are you likely to need surgery or costly procedures? Or is your disease well managed? You may need little more than prescription refills and periodic checkups. While it’s impossible to predict exactly how healthy you’ll be, having an idea of what’s in store will help you crunch numbers and see what options are best.

Too many people buy health insurance based on the monthly premiums alone, Rosenberg says. Big mistake. You should never automatically choose the most expensive plan or the least expensive or even the one in the middle, he says. Look at the plan’s copays, annual deductible and out-of-pocket maximum. Then make yourself a worksheet. Look at how much you may spend in the next year going to doctors and whether you’re likely to be hospitalized.

“If you have a chronic condition and use a lot of health care, the plan that is the most expensive to purchase could end up being the lowest cost given how it covers your needs,” Rosenberg says.

In addition, here are 5 big mistakes when buying a health plan at work.

Check the provider networks and medications

Another major consideration when you have a chronic illness: What providers and hospitals are in the plan’s network? Most plans pay more when providers participate in their networks. Some plans provide some coverage for out-of-network providers and some don’t.

Checking that your doctors are in network is always important but even more so if you have a chronic condition, says Pamala McIntire, a benefits advisor with Reames Employee Benefits Solutions Inc. in Daytona Beach, Florida.

Don’t assume because your doctors were in your plan this year that they will be next year. Health insurers change their plan networks all the time. Plans generally list their providers on their website. You also can call your doctor’s office and ask. If you call, be sure to be very specific about the plan name because some doctors may take a plan from your company (Aetna, Blue Cross Blue Shield, UnitedHealthcare, etc.) but not your particular plan from that insurer.

Even seeing your doctor on the list doesn’t guarantee that he’ll be there the whole year. Here’s what to do when your doctor disappears from your plan’s provider network.

If you have been seeing a doctor for your condition and he won’t take your insurance next year, you have a big decision to make.

“You have to decide if you want to continue to see your doctor or choose another doctor who is in your plan,” Rosenberg says. “You have to decide how important your relationship with your current provider is.” You also have to consider whether you could afford to pay more toward your care if you go out of network.

You should also check whether your medications are covered. Most plans have “formularies,” or lists of preferred drugs that they cover at a higher rate. “Someone who has a chronic health condition is more likely to take medications on a regular basis,” Rosenberg says. Some plans might require that you get your medications by mail order. That requirement could play into your choice, Rosenberg says.

Consider your lifestyle and a health plan’s pre-certification requirements

Think about your lifestyle as well, McIntire advises. If you have a chronic condition and travel a great deal, you might want to choose an HMO. Here’s why: HMOs must treat emergency room visits and resulting hospital stays, no matter where the ER is, as in-network. Preferred provider organizations (PPOs) or point of service plans (POS) don’t have to. If you have a PPO or POS and end up being admitted to the hospital while out of town, you could be billed for out-of-network follow-up care by the different providers who treat you.

On the other hand, McIntire says, HMOs tend to have more restrictive formularies. So if you have a chronic condition and need a new prescription, it may not be covered. Also, HMOs often require you to get pre-certification for treatment or tests or they won’t reimburse you for them. You have to weigh the pros and cons of each of your choices, she says.

Employers today often provide online tools to help you chart your possible copays and out-of-pocket costs. Take full advantage of them, Rosenberg says.

Finally, Terry says, see whether the plan offers a disease-management program for your chronic condition. The plan may offer close coordination of care to help you manage your disease better. And that could be a factor in its favor when you’re making a health insurance comparison.

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