Does Health Insurance Cover Multiple Sclerosis Treatment?

Multiple sclerosis (MS) affects everyone differently, with symptoms ranging from mild to disabling. At any level of disability, managing MS over a lifetime can become a financial burden.

The National MS Society estimates that living with MS costs upward of $70,000 per year per person. Of course, your experience may be different.

This article discusses health insurance coverage and financial assistance for people living with MS. 

Financial Aid for Multiple Sclerosis

Your cost of care can vary greatly depending on your health insurance coverage.

Medicare

Medicare is health insurance for people 65 or older, but you may be eligible earlier if you have permanent disabilities due to MS. Medicare is broken down into several parts as follows:

• Part A covers inpatient care in a hospital or nursing home. It also covers some in-home and hospice care. Most people don’t have to pay a monthly premium.
• Part B covers visits with healthcare providers and other healthcare professionals. It also covers durable medical equipment, outpatient services, and physical and occupational therapy. Most people pay a standard premium.
  
• Part C is also known as Medicare Advantage. This is private insurance that provides similar benefits as Medicare.
  
• Part D offers prescription drug coverage.
  
• Medigap is a supplemental insurance for Medicare. It pays for some out-of-pocket costs.
  

Medicaid

Medicaid is a federal and state health insurance program. It covers people with a low income and people with disabilities. Eligibility requirements vary from state to state.

Government Assistance Plans

In the United States, nearly 30% of people with MS receive benefits through SSDI.

You must have worked in jobs covered by Social Security and have a qualifying disability. Multiple sclerosis is a qualifying disability when it involves:

• “Disorganization of motor function in two extremities resulting in an extreme limitation in the ability to stand up from a seated position, balance while standing or walking, or use the upper extremities.”

OR

Marked limitation in physical functioning, and one of the following:

• Understanding, remembering, or applying information; or
• Interacting with others; or
• Concentrating, persisting, or maintaining pace; or
• Adapting or managing oneself

Private Insurance

Private health insurance is insurance not provided through a government agency. For example, insurance you get through an employer or through an insurance agent.

You can also compare plans and sign up through the Health Insurance Marketplace. Marketplace plans must cover certain essential benefits. Also, your income level may qualify you for tax benefits and premium savings. Certain life events allow you to sign up during a special enrollment period.

How to Check If Your MS Treatment Is Covered

There are multiple factors you should check to ensure your treatment is covered by your insurance, including finding a healthcare provider within your network and confirming your insurance covers the services and medications you need.

Checking Your Healthcare Provider

In most cases, you’ll want to find healthcare providers who are within your policy’s network. This will help keep your out-of-pocket costs down. Depending on your policy, you may have limited or no coverage when using out-of-network healthcare providers.

Your healthcare provider's office may have a staff member dedicated to dealing with insurance. In many cases, they can work directly with your insurer to verify your benefits. You can call or log in to your insurer’s website to find network healthcare providers.

Checking Your Services

Call your insurer or check your plan’s Summary of Benefits and Coverage page. It will list services covered by your plan, along with copays or coinsurance.

Checking Your Plan’s Formulary

Your plan’s formulary is the list of drugs covered under your policy. It will also show your copay. The formulary is divided into tiers for generic, preferred brands, and specialty medications. The higher the tier, the higher the out-of-pocket cost. You can usually find the formulary under your plan’s Summary of Benefits and Coverage.

Disease-modifying therapies (DMTs) for MS are considered specialty drugs. They tend to be among the most expensive on the formulary list.

Determining Total Out-of-Pocket Costs

Out-of-pocket costs are those you must pay in addition to monthly premiums. These costs include:

• Deductibles
• Copays
• Coinsurance

Health policies generally have an annual out-of-pocket maximum. Once you hit the maximum, your policy covers 100% for the rest of the year.

MS Treatment Cost

DMT prices are the biggest expense related to MS treatment. In the United States, many DMTs cost more than $90,000 per year. Your health policy may cover some or all of this cost.

Summary

Most insurance policies must cover some portion of your MS treatment. What you pay out-of-pocket depends on the details of your policy. You can avoid getting caught off guard by checking your benefits in advance of treatment.

If you don’t currently have health insurance, you may be able to enroll through the Health Insurance Marketplace. And most pharmaceutical companies have financial assistance programs to help with the cost of DMTs.

You can learn more about managing MS-related expenses through your healthcare provider’s office or calling your insurer directly.

A Word From Verywell

Living with a chronic illness is challenging enough. And the financial reality of MS can be daunting. Fortunately, there are resources designed to help you navigate life with MS. Researching your options takes time but could prove well worth the effort.

Whatever your concerns about MS, you’re certainly not alone. You can find support and connect with others who “get it” through your local chapter of the National MS Society.