Good medical coverage is one of the most important assets you can have, especially when you have a chronic condition such as arthritis. For more information on this subject, contact your local chapter.

What should I look for in a group policy or an individual policy?

Check for the following:

• Coverage for arthritis. Pay attention to whether the plan denies coverage for care related to your type of arthritis. The refusal could be for a certain length of time or permanently. The general policy provisions will seldom exclude coverage for arthritis, although an individual policy may specifically exclude it. 
   
• Outpatient and inpatient care. Look for a policy that provides a benefit for doctor visits and other outpatient services, as well as for surgery and hospital care. The plan should cover any type of recognized surgery to relieve pain and promote function. 
   
• Choice of doctor. If you buy a managed care policy, such as those offered by a Preferred Provider Organization (PPO), an Exclusive Provider Organization (EPO), or a Health Maintenance Organization (HMO), you may be limited to seeing only the health-care providers in the plan network. If your physician isn't in the network, will you feel comfortable going to a new doctor? Can your current doctor refer you to someone in the network? Make sure you will be able to get care from specialists, such as rheumatologists, when you need them.
   
• Rehabilitation coverage. This type of provision should include physical, occupational and vocational therapy. Also look for coverage for assisting devices, such as walkers, braces, splints, bath rails and computer-assistance devices. Carefully evaluate any limitations on these benefits.
   
• Prescription drug coverage. Ask to see the insurance plan's "formulary," which is a list of drugs the plan will cover. Are your current medications on the list?
   
• Laboratory and other monitoring procedures. These procedures should be covered not only to diagnose problems, but also to ensure your medicine and other therapies are working effectively. 
   
• Costs. Weigh the benefits of the policy against the costs. Costs include the premium, deductible, copayment, out-of-pocket cap, and annual as well as lifetime maximum benefits. Also look to see if some benefit levels are reinstated each year.
   
• Health plan report card. Check to see if a consumer group has rated the health-care plan for customer satisfaction and quality of care. 
   
• Service. Call the insurer's customer service phone number to see how quickly you can get help.

I'm covered under a group health insurance plan at work. Is that the best I can do?

In general, group plans provide more benefits for less cost than buying your own health insurance-even if you have to pay part of the premium. Here are some things to keep in mind when considering an employer's plan:

• Some employers offer several different plans to their employees. If you have that option, compare each plan's benefits relative to your needs. In particular, look at the plan's benefits for prescription drugs, physical and occupational therapy, assisting devices and access to specialists. Don't base your choice only on cost. A plan may seem to be a bargain, but its coverage may fall short.
   
• If your spouse has a health insurance plan at work, compare it with yours. You may decide that you'll have better coverage under your spouse's plan. 
   
• Understand that an employer can offer a group plan that excludes coverage across the board for a chronic condition such as arthritis. However, an employer cannot exclude coverage for one particular employee's condition. In addition, an employer cannot ask you to pay more for your health insurance because you have arthritis. And, an employer cannot base a hiring decision on whether your medical condition will cause the employer's insurance premiums to increase. 

What should I do if I leave my job?

If you leave your job, it's important to keep your medical coverage in place until you are covered under a new plan. COBRA, a federal law, allows you to do that. (See Changing Jobs)

If I'm not eligible for COBRA or have other problems getting coverage, what should I do?

• If you are leaving a job, find out if-or how long-your insurance coverage will continue after your last day of work. Consider converting your group policy to the insurance company's individual plan. You will pay more for fewer benefits, but you may have difficulty getting an individual policy any other way. Make sure your converted policy covers your arthritis.
   
• Determine whether you can be covered under your spouse's policy.
   
• Ask about health-care plans through any unions, trade associations or professional societies to which you belong. Note that these policies may require underwriting, which means you will give your medical history to the insurance company. There is no guarantee you will be eligible for these policies.
   
• Talk with an insurance agent about the availability of temporary coverage, as well as other options. 
   
• Determine whether your state has an insurance program for hard-to-insure individuals.
   
• Call your hospital's social worker or the Arthritis Foundation for suggestions.
   
• You may qualify for Medicare or Medicaid. 
   
• You may qualify for workers' compensation.
  

©2001. National Endowment for Financial Education. All rights reserved.

Note: Certain content areas in this material are current as of the publishing, but legislative and regulatory changes as well as new developments may date this material over time. This content is meant to provide general financial information; it is not meant to be a substitute for or to supersede specific professional or legal advice.