Key Health Insurance Benefits for People With Arthritis

Knowing what your plan must cover can help you get the treatment you need.

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Finding health insurance that’s both affordable and meets your needs is never easy, since lower monthly premiums almost always mean either less coverage or higher deductibles, co-payments and other out-of-pocket expenses.  

That’s especially true when you have a chronic condition, like arthritis, that often requires a lot of care, including specialists and expensive medications. But there are ways to find the right balance – if you know what to look for. 

Here are five important benefits to consider when choosing health insurance.

1) Coverage for the drugs you need

Why it’s important: Recent research shows that access to a class of drugs called biologics – genetically engineered proteins derived from human genes or from a living organism – and other innovative drug therapies make a dramatic difference in keeping patients with rheumatoid arthritis (RA) working. Early treatment access to these drugs is critical, says Kimberly Jinnett, PhD, research director of the Integrated Benefits Institute in San Francisco.  

Yet, Jinnett and other experts say that most insurance plans are more likely to fully cover generic drugs when they’re available than brand-name drugs. If the prescriptions you’re taking or might want to take in the future are available only as brand-name drugs, your out-of-pocket costs may be quite high – or they might not be covered at all.

For example, if your insurance pays only 70 percent of the cost of one of these new RA drugs, you could find that you’re paying $6,000 a year out of pocket for a drug that costs $20,000 at the suggested dose.

What to do: Make a list of all the drugs you’re taking, and compare it to what’s called the drug formulary of any plan you’re considering (each insurance company’s list of approved drugs).

Tip: Call each plan’s benefits department or member services department to get details approved and unapproved drugs. Also, ask if it has information describing your specific condition.

2) Good coverage for physical and occupational therapy

Why it’s important: Physical and occupational therapy are some of the best ways to help prevent or ease joint pain and joint damage. A 2009 study, for example, found that those who didn’t receive comprehensive occupational therapy for RA were more likely to be disabled and unable to work. Most health insurance plans, however, including Medicare, put a cap on coverage – and experts say that health plans will be able to continue to cap these services under the new health law.

What to do: Look for either no cap or a high annual cap on physical and occupational therapy; talk to someone in your human resources department or the plan’s representative to find out. Many Medicare Advantage plans, for example, don’t apply a cap.

Tip: If you’re considering joint replacement surgery, good coverage for physical and occupational therapy are even more important, since both are needed before and after surgery.

3) Special programs to ensure comprehensive, coordinated care

Why it’s important: According to Jinnett, research shows that a health plan that takes a coordinated approach to your arthritis care – ensuring that you get the information and support you need and that all your providers have the same information about your care, including any tests you’ve taken, your medications, and your medical history – can make a big difference in your quality of life. 

“Research shows that the label – HMO, PPO or standalone – matters less than how integrated the care is,” she adds. That’s even more important if you’re seeing specialists in addition to your primary care doctor: a rheumatologist, physical and occupational therapists, and a surgeon or mental health counselor, for example, since all your providers should be working together to improve your care.

What to do: Make sure there’s a program specifically targeted to your condition, whether it’s osteoarthritis, rheumatoid arthritis, or some other chronic condition – and that it includes personal attention from (and access to) a trained medical provider.

Tip: Look for a plan that keeps electronic health records (EHRs); that’s usually a good indicator of an integrated, comprehensive approach to your care.

4) Access to the specialists you want

Why it’s important: Getting a referral to the right specialist can make a critical difference at several key stages. For starters, because there are many types of arthritis and many treatment options, it’s important to be correctly diagnosed and treated by someone who knows your specific condition. That’s your best chance to prevent joint deformity and disability.

Also, having access to highly competent specialists, such as a rheumatologist, can help monitor and treat your condition at every step.

What to do: To gauge the quality of the specialists that belong to the health plan you’re considering, ask a doctor you trust to look over the list of arthritis specialists, physical and occupational therapists, and surgeons included – even if you don’t need one today.

Tip: One key to good access to specialists, says Jinnett, is to choose a good primary care physician – someone who won’t block access to specialists but will treat you as a whole person and steer you to the right people. “You want your primary care doc to know you better than anyone,” she adds.

5) 24-hour hotline with clinical expertise available

Why it’s important: Being able to talk to a trained medical provider any time of day can help you make critical decisions quickly and conveniently about things like drug side effects or pain.

What to do: When comparing plans, be sure that the 24-hour-nurse support provided is a person and not just a collection of recordings on specific topics – and that access doesn’t involve going to an emergency room. (A plan that offers access to an urgent care facility, however, is a good thing.)

Tip: To judge quality of the 24-hour hotline, ask someone in your human resources department or the plan’s representative to describe exactly how it works.

For more information: If you have questions about any health plan you’re considering – including specific questions about caps on physical or occupational therapy or drug coverage, talk to someone in your company's human resources department or the plan’s representative.

The Arthritis Foundation is the leading organization 
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lives of individuals with arthritis. You can help!