Obtaining health insurance that includes hospitalization, major medical coverage, and prescription benefits is essential for any person with a disabling chronic health condition, such as psoriatic arthritis (PsA). People with PsA will have a lifetime of healthcare needs and there is a considerable cost associated with those needs.
If you live in the US, where the health insurance marketplace is particularly complex, being well informed about your health insurance options will help ensure that you and your family have both the health services and financial protection you deserve.
Understanding health insurance options
While you don’t need to be an expert when it comes to insurance, a basic understanding of some key concepts and terms will come in handy as you consider your health insurance options.
Traditional fee-for-service health insurance plans work by allowing policy holders to obtain and pay for health services of their choice and get reimbursement by their policy provider according to the specific terms of their policy. One element of fee-for-service plans that appeals to consumers is that they allow you to choose your own provider.
Managed care health insurance plans contract with a specific network of health providers (doctors, hospitals, pharmacies, etc) that provide services to policy holders. People with managed care plans usually pay little or nothing out of pocket for services within the allowed network of providers. The three most common types of managed care plans are health maintenance organizations, preferred provider organizations, and point of services plans.
Health maintenance organizations (HMOs) are the most restrictive type of managed care plans. In HMO plans, policy holders are strictly limited to providers and services within a specified network. In HMOs, patients need referrals from their primary care physician (PCP) to see specialists, such as a rheumatologist. On the positive side, premiums tend to be lower for these plans.
Preferred provider organizations (PPOs) provide another lower cost option for obtaining care through a network of providers who have contracted with the health insurance company to offer discounted rates to policyholders. Patients are able to choose any health care provider, including specialists, without a referral. However, if they choose to receive care out-of-network, then they must pay for a larger portion of the costs. This type of plan accounts for most of the job-based group health insurance plans that exist today in the US.
Lastly, some health insurance companies offer a point of service (POS) plan which takes a hybrid approach combining elements of FFS, HMO, and PPO plans. With POS, policyholders can choose who to see each time there is a need for medical care and are not limited to a specific network.
In today’s health insurance market, managed care plans are much more popular and fee-for-service plans are rare. Interestingly, one example of a pure fee-for-service plan is Medicare.
How do I know what I’m eligible for?
In the past, eligibility rules for health insurance plans were typically based on eligibility criteria or rules made by the sponsor of the plan spelling out who qualified for a specific plan. With the Affordable Care Act (ACA), eligibility rules have undergone significant changes as reforms have been gradually adopted. In the US, a person can get health insurance either through the government or through a private insurance company. The tables shown below lay out the essentials on insurance eligibility by type of government and private plan.
Eligibility requirements for government insurance programs )—including Medicare, Medicaid, Veterans’ benefits, TRICARE, Federal Employee Health Benefits Program (FEHB), State Child Health Insurance Programs (S-CHIPs), or insurance programs for employees of state and local governments)—vary by program. Eligibility is determined by whether a person:
- Qualifies for a government entitlement program, including Medicare or Medicaid
- Was or is employed by a government agency, including the military
- Is a family member of someone who works or worked for the government, who was eligible for such an insurance program
Many private health insurance plans include group coverage as a benefit of employment, membership in a union or other organization, individual plans, high-risk health insurance pools, and Medicare supplemental insurance (sometimes referred to as Medigap plans).
Government Insurance Programs
- Source of coverage for most people 65 years or older
- Medicare Parts A, B, C, and D, there are several options available for organizing and accessing care, including prescriptions, so it is important to get advice about Medicare options if you are eligible
- People younger than 65 years who are disabled (including those with PsA) may qualify*
- Medical assistance entitlement program for people and families with low income, with benefits varying from state to state
- Provides coverage for a variety of long-term care services, including stays in nursing homes
- Coverage for children in families that do not qualify for Medicaid
- Comprehensive healthcare to veterans with service-related disabilities
- Health benefit program for active duty and family, reserves (under certain conditions), retired military and family
- Offers both fee-for-service and managed care plans
- Choice of health plans for federal, non-military employees and eligible family members
- Available from date of enrollment without restrictions
- May continue (under certain conditions) for employee and/or eligible family members beyond retirement and death of employee
- Health benefit plans for employees and eligible family members
*Must meet Social Security Disability Insurance or SSDI criteria. A 24-month waiting period is required before coverage begins.
Private Health Insurance
- Offered to employees and often to family members
- Choice of different plans typically offered
- Can be either fully insured or self-insured
- Purchased by individuals to cover themselves and their families
- With ACA, these types of plans can not be denied to someone on the basis of a pre-existing condition and must be made affordable
- Supplemental insurance that can be purchased to pay costs not covered by Medicare
- Coverage for state residents who are uncoverable due to a pre-existing condition
- Largely made obsolete by the ACA, covered state residents who are uninsurable due to a pre-existing condition
- Most states have closed their pools to new enrollees or shut down the program altogether since the ACA mandates that pre-existing conditions be covered by insurance
- Temporary extension of coverage for people who lose employment-group health coverage through loss of employment, divorce, retirement, death of spouse, disability, or Medicare enrollment of spouse
COBRA refers to the health benefit provisions from the Consolidated Omnibus Budget Reconciliation Act of 1985.
*It is important to find out which type applies to you and what it means for your coverage. Unlike fully insured plans, self-insured plans are not regulated on a state level and this may affect you if there is a dispute concerning your legal rights as a member of the plan.
PsA and the Affordable Care Act
The Patient Protection and Affordable Care Act (also referred to as the Affordable Care Act [ACA]) became federal law in 2010. Over a period of 10 years as the law is phased in, it will make a series of reforms to the health insurance system and the federal and state laws and regulations that affect that system. It is uncertain whether the federal government will dismantle the ACA or dramatically change it.
How does the Affordable Care Act affect me if I have PsA?
If you have psoriatic arthritis it is important to get the facts about what the ACA means to you now and what it may mean to you in the future. The US Centers for Medicare & Medicaid offers a website with the latest information on how the ACA may apply to you at the ACA website. It offers several useful tools for finding coverage, how to use your coverage, and suggestions for finding health insurance outside open enrollment dates.