Life with MS

Navigating a Change of Insurance with MS

By Matt Cavallo


Navigating the maze of health insurance can be confusing and frustrating. Once you have learned the lingo, the next challenge is to select a health insurance plan that will help you successfully manage your MS care. Choosing the wrong insurance or not knowing your insurance rights can lead to more relapses and poor health outcomes. The following scenario offers practical tips and takeaways for selecting a new health insurance plan when living with MS.
Imagine you were just informed that your employer is switching insurance providers and there will be an open enrollment period. The open enrollment period provides you with three options: an HMO plan, a PPO plan, or a high deductible plan. How do you choose a plan that is right for you?
The first thing that you will want to consider is what healthcare services you will need for the following year. In this scenario, you anticipate that you will have two neurology visits, two MRIs and take an oral MS treatment that gets refilled once a month. That means without any catastrophic health episodes, such as an MS exacerbation, you will need to have at least four health appointments and 12 prescription refills, all in addition to your annual physical.
Since you are requiring a higher level of care, you probably don’t want to choose the high deductible plan. Sure, that plan has the lowest premium, but if you do not experience enough health episodes to cover the deductible, all your health expenses for the year could end up being out-of-your-pocket.
So then you can narrow down your options to two. The PPO plan allows you to see your MS specialist without a referral, but has a higher premium than the HMO plan. The decision here comes down to whether or not you want to coordinate your care through a primary care physician. If you see multiple specialists, in addition to your MS neurologist, having a PCP coordinate care may be a good option. If MS is your chief concern and you are otherwise healthy, you may want to pay a little extra each month for the convenience of skipping the PCP and going straight to your MS specialist.
Next, you want to look at the in-network providers and formulary. You will want to confirm that your current MS specialist is in-network with the new insurance plan. If your current MS specialist is not in-network, you will have to decide whether to continue care with this specialist. Out-of-network claims are more expensive than in-network claims. (A tip if you find yourself in this situation when choosing insurance plans: If your MS specialist is not in-network and you are going to switch to an in-network option, make sure that you go to your current provider and sign a release of medical records. You will want to make sure that your new specialist has access to your entire medical history.)
You will also want to ensure that your current MS treatment is on the formulary. Whether your treatment is on the formulary or not, you may have to prove medical necessity to continue treatment. When switching insurance, it is ideal to maintain continuity of care. As a person living with MS, you can be proactive about managing this transition.
If you have selected an HMO plan, it is important to get established with a primary care physician. You will want to make an appointment with the PCP as soon as the plan is effective in order to get a referral to see the MS specialist. Once you have that referral, contact your MS specialist to get scheduled for an appointment. If you opted for the PPO, you can skip this step.
The MS specialist may have to submit for prior authorization before the appointment. During that appointment with your MS specialist, your neurologist will write a prescription for your MS treatment.
If you get these appointments scheduled, you should have no delay in treatment. It is also recommended to get a letter of credible coverage from your previous insurer, so that your new insurance knows your MS has been managed continuously by another insurer. This may also help with the referral and authorization process. Health insurers cannot deny coverage because of a pre-existing condition, but it is a good idea to collect as much information as possible from your previous insurer to ensure the continuity of care.
Let’s say that you follow all these steps and you get a letter in the mail stating that your MS treatment got denied because of medical necessity. If you get a denial, it is important to know that it is not the end and that you have the right to appeal the decision. Your MS specialist who wrote the prescription will also get a copy of the denial.
If you get a denial, first call your MS specialist. There is a chance that they simply need to provide additional documentation to support the medical necessity of your treatment. Also, call the insurance company and let them know your intention to appeal the decision. The insurance company will have patient advocates and case managers that will help you with the appeal. Your MS specialist may also call for a peer-to-peer review with the insurance company to get your treatment approved.
If all options have failed and you have exhausted all appeals, you have the right to file a grievance with the insurance company. To file a grievance, you should follow the process outlined in the policy, or contact the health and human services branch of your local government
While the details of your situation may be different, hopefully this hypothetical scenario has helped you to understand a bit more about your insurance options. Switching insurances shouldn’t mean that you have to delay your treatment or care, but it is up to you to be proactive and make sure that the transition to a new insurer is seamless.