How to Navigate Health Insurance When Living with a Chronic Health Condition

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.

Understand what’s in the medical network
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.”

Get insurance info from your employer
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.

Organize receipts to understand expenses
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.

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