Choosing health insurance: What you should consider if you have a chronic health problem

A Disease Management post on 11/1/2016.   Topics:  ,

Health insurance and chronic conditions

As you think about which health insurance plan you’ll choose for next year, there are a number of different factors you should consider, including:

  • monthly premium
  • yearly deductible
  • co-payments
  • whether prescription drugs are covered
  • whether you have coverage while traveling
  • how the plan is rated for quality and customer service

But if you’re living with a chronic condition like diabetes, asthma, heart disease, or arthritis or if you’ve been diagnosed with a serious illness such as cancer, there are several other factors you should also think about when choosing a health insurance plan. The goal is to make sure you have access to the care you need from the healthcare providers you prefer.

What to consider when choosing your health insurance plan

Before signing up for a health insurance plan, get the answers to these questions:

  • Are the doctors I see regularly and my preferred hospitals included in the plan? Check each plan’s list of participating providers to find out if your primary care physician and the specialists you see to manage your chronic condition are part of your network. If you’ve been diagnosed with a serious illness like cancer, you’ll also want to make sure all the specialists involved in your treatment and hospitals or other healthcare facilities where you prefer to receive treatment are covered by the plan. If the physicians you see are outside of the plan’s network, you could end up paying significantly more out of pocket for your care.
  • What are your anticipated healthcare needs? Consider how many times a year you see the physicians who are treating you. Think about how often you visit an emergency room or urgent care provider and how frequently you’ve been hospitalized in the past year. Will you need surgery or other types of intensive treatment in the coming year? With that information in mind, carefully review the benefits the health insurance plan offers to make sure all the types of care you need are covered and that the maximum amount the plan will pay for those types of care is not significantly lower than your anticipated costs.
  • Are my medications covered? Check the plan’s list of covered medications, called a formulary, to make sure any drugs you take regularly are included. These lists often break medications into several categories—generics, preferred, non-preferred, and excluded. The amount of money you pay out of pocket will be greater if your medications are on the non-preferred or excluded list. Also find out if prescriptions require a co-pay (a set amount you pay each time you fill a prescription) or co-insurance (a percentage of the cost of the medication you pay each time you fill a prescription). If the medications you take are expensive, the amount you pay out of pocket in co-insurance could be significant.
  • Do you need a referral to see a specialist or receive certain services? If your care is managed by one or more specialists, you may prefer a health insurance plan that does not require your primary care physician to see you first and refer you to a specialist. A plan that does not require pre-certification for services like diagnostic tests, in-hospital care, and surgery can also help streamline and simplify your access to care.
  • Does the plan offer special programs to help you manage your condition? Many health plans offer phone consultations with nurses who can answer questions about your treatment and medications and help you stay on track with your care plan. Plans may also offer discounts on wellness programs that can help you manage lifestyle factors that can affect your condition such as gyms and exercise programs, weight loss plans, smoking cessation, and stress management programs. A health advisor can also connect you with specialists who can help you manage lifestyle factors or lessen the impact of side effects caused by treatments for your condition.


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