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If you have a chronic medical condition, you’re well aware of how important it is to be able to access the care you need. And for most of us, access to medical care is directly linked to our health insurance coverage.
Particularly if you’re newly diagnosed with a chronic condition, selecting the health insurance that will best meet your needs can feel overwhelming. But the more you understand about health coverage for chronic conditions, the easier it will be for you to navigate the system and ensure that you have the right coverage.
Do all health insurance plans cover chronic conditions?
Most health plans cover chronic conditions. But it’s important to understand the details of any health plan you’re considering, and there are some nuances to consider:
- Employer-sponsored health plans cover pre-existing medical conditions. This was already true as a result of HIPAA, but the ACA eliminated pre-existing condition waiting periods for people who didn’t have prior coverage.
- ACA-compliant individual/family (self-purchased) plans also cover pre-existing conditions with no waiting periods, thanks to the ACA. If you’re shopping for coverage, here’s how you can determine whether it’s ACA-compliant.
- Individual/family and small-group health plans with effective dates of 2014 or later are required to cover the ACA’s essential health benefits. This will encompass medically necessary care that’s needed for most chronic conditions, although there are some exceptions. (Infertility, for example, does not have to be covered unless a state requires it.) In most states, small-group plans are available to employers with up to 50 employees, although there are four states – California, Colorado, New York, and Vermont – that put the threshold at 100 employees.
- Large-group and self-insured health plans do not have to cover ACA’s essential health benefits. Most employer-sponsored plans are fairly robust, but the coverage requirements that apply to large-group and self-insured plans are not as strict as those that apply to individual and small-group plans. For example, although virtually all employer-sponsored plans cover prescription drugs, they are not required to do so. All non-grandfathered employer-sponsored plans are required to cover certain preventive care without cost-sharing, but the rest of the essential health benefits are optional for self-insured and large-group plans. (In order to comply with the employer mandate, large employers must provide “substantial coverage” of inpatient and physician services, and the plan must cover at least 60% of healthcare costs for a standard population.)
- Plans that aren’t subject to the ACA are not required to cover pre-existing conditions or any essential health benefits. This includes short-term health insurance, fixed indemnity plans, direct primary care plans, and health care sharing ministry plans.
Four health insurance considerations for people with chronic conditions
If you have a chronic condition, you’re likely aware of how important your health insurance is. But especially for those who have recently been diagnosed with a chronic condition, it can be challenging to know what aspects of health coverage are going to matter the most. Here’s what you need to pay attention to when you’re selecting a health plan:
- Provider network. If you have a chronic condition, you’ll likely need to see certain medical providers on a regular basis. You might need inpatient care, or access to certain specialists, including some who might not be in your local area. Depending on the condition you have, the provider network might be one of the most important aspects of picking a health plan. And keep in mind that provider networks can change over time, so you may have to switch plans from one year to the next in order to maintain access to the providers you need. If you have a provider you want to continue to see, you’ll want to call their office and confirm that they’re in-network with the health plan you’re considering.
- Out-of-network coverage. Depending on the condition you have, you may find that you need to travel outside your local area to see specialists. If that’s the case, you’ll want to pay close attention to the scope of the provider networks for the plans available to you, and also to whether the plans provide any coverage for out-of-network care. Out-of-network care is covered in emergencies or when an out-of-network provider treats someone at an in-network hospital. But other than that, HMOs and EPOs generally don’t cover out-of-network care at all. If you get a PPO or a POS, it should include out-of-network coverage, but you’ll want to make sure you understand how high your out-of-pocket costs would be to access providers outside the network, if necessary. Here’s more about choosing a type of managed care plan.
- Covered medications. Although the vast majority of health plans cover prescription drugs, they each develop their own formulary, or covered drug list. This is why certain drugs are covered by one plan but not another. And even if two plans both include a certain drug on their formulary, they might place it in different tiers. (Out-of-pocket costs vary by tier on most plans.)
- Total costs, including out-of-pocket costs and premiums. When you’re dealing with a chronic condition, your costs might not be as important as ensuring access to the providers and medications that you need. But total costs are still a big part of the decision-making process. Total costs include both premiums and the bills you get when you receive medical care:
- Premiums: The amount that you pay each month for your coverage will vary depending on where you get your insurance and the specific plan you select. If you get your coverage from an employer, the employer likely subsidizes a significant portion of the premium. And if you buy your own health insurance, you’ll likely find that you’re eligible for subsidies via the exchange/marketplace.
- Out-of-pocket exposure: On virtually all health plans (except grandmothered and grandfathered plans, and plans that aren’t subject to ACA regulations), the maximum out-of-pocket limit for covered, in-network care is $9,100 in 2023 (increasing to $9,450 in 2024). But there are lots of plans available with out-of-pocket caps well below these limits. And if you have a modest income and you buy your own health insurance, you might find that you’re eligible for cost-sharing reductions, which will reduce the amount you have to pay when you need medical care.
How does the government protect health coverage for people with chronic conditions?
Federal and state government rules do a lot to protect health coverage for people with chronic conditions. For example:
- HIPAA and the ACA ensure that virtually all health plans must cover pre-existing medical conditions without waiting periods.
- The Mental Health Parity and Addiction Act, along with the ACA, ensure that if a plan covers mental health care, it must do so on the same terms that it covers medical/surgical care.
- The ACA ensures that individual and small-group health plans cover the essential health benefits.
- The ACA also ensures that virtually all health plans have a cap on out-of-pocket costs for in-network care.
- For people with Medicare, the Inflation Reduction Act limits insulin out-of-pocket costs, and will cap Medicare Part D prescription drug out-of-pocket costs starting in 2024.
- Some states have placed caps on how much a state-regulated health plan can require a member to pay for prescription drugs, and numerous states have taken various actions such as limiting insulin copays or banning copay accumulators. States can also impose benefit mandates that go beyond what the ACA requires, such as coverage for infertility treatment. (Note that states cannot regulate self-insured health plans, and the majority of people with employer-sponsored health coverage are on self-insured plans.)
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.