Commercial and Employer Plans
If you are in the workforce, you have the option to use the major medical insurance plan provided by your employer. This plan is managed by a private insurer for your employer or is self-funded (i.e., the employer is the insurer). You can also buy health coverage directly from an insurer through the health exchange or the insurer’s website. All major medical plans include drug coverage. Supplemental, catastrophic, vision and dental coverage are offered as stand-alone plans. (More information about these plans is provided below).
In some instances, health benefits provided by an insurer or employer may be different in each state depending on state law. So review plan details carefully if you move to a different state even if you are choosing the same insurance company or working for the same company.
When choosing a plan, it’s a good idea to think about your total health care costs, not just the amount (premium) you pay each month. Out-of-pocket costs have a big impact on your total spending on health care. If you expect to need to see your doctors often or fill several prescriptions, you might want to select a plan that has higher monthly premiums, but will pay more of the costs when you need care. Some plans restrict your provider choices or encourage you to certain doctors, hospitals, pharmacies and other medical service providers (in-network providers). Other plans will cover out-of-network expenses but you will pay a greater share.
Keep in mind that insurers may have different networks for different plans. So review the network associated with a plan and make sure it includes the providers (e.g. doctors, hospitals, urgent care clinics, physical or occupational therapists, pharmacies) you use regularly. To confirm whether a provider is in-network, it’s best to check with your insurer rather than the provider. Providers may not be familiar with your plan, and while they may do business with an insurer, they may not accept all plans the insurer offers.
Understanding plan differences will help you to make the best decision for yourself or a family member who has arthritis. The most commonly used plans for major medical care include:
- Exclusive Provider Organization (EPO): A managed care plan where services are covered only if you use doctors, specialists or hospitals in the plan’s network (except in an emergency).
- Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
- Point of Service (POS): A type of plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You will choose a primary doctor from a list of participating providers.
- Preferred Provider Organization (PPO): A type of health plan where you pay less if you use providers in the plan’s network. You can use doctors, hospitals, and providers outside of the network without a referral but may have higher out-of-pocket cost for services than you would if you used an in-network provider..
- High Deductible Plans (HDP): A type of health plan where you pay all your healthcare costs until you meet your deductible, then the insurer starts to pay a portion of the costs. This plan is usually combined with a health savings account (HSA) or a health reimbursement arrangement (HRA).
The chart below provides additional information about these plan options.
Here are some issues to be aware of as you are evaluating these plan options.
- If you use a doctor or facility that isn’t in the HMO’s network, you’ll pay the full cost of the medical care.
- You may experience delays in seeing a specialist. Or your PCP may not agree with your request for a referral. Then you may need to make your case directly to the insurer.
- There’s a possibility that your preferred doctors leave the network so make sure to check the list each year before you re-enroll in the HMO.
- You’ll need to pay out-of-network providers directly and then file a claim for reimbursement. If the PPO agrees to cover only a part of the amount due to the out-of-network provider, you are responsible for the balance. Some services won’t be covered until you meet your deductible.
- You’re responsible for coordinating your care among specialists.
- There’s a possibility that your preferred doctors leave the network so make sure to check the list each year before you re-enroll in the PPO.
- You pay for expenses with pre-tax dollars. The money in the HSA or HRA rolls over from year to year and can move between jobs.
- You pay 100% of your health care costs until you satisfy your deductible.
- Plan will pay for out-of-network care if you are referred by your PCP.
- You will need to satisfy your out-of-network deductible before the plan reimburses out-of-network (OON) coverage, and you’ll pay more for OON care.
- You’re responsible for getting preauthorization if the plan requires it. Otherwise you’ll pay 100% of the costs.
- There’s a possibility that your preferred doctors leave the network, so make sure to check the list each year before you re-enroll in the POS plan.
- If you use an out-of-network provider, you will pay 100% of the costs.
- There’s a possibility that your preferred doctors leave the network, so make sure to check the list each year before you re-enroll in the EPO.
There are two additional health insurance coverage options. However, they are rarely ever used as main health coverage and are not suitable as the only source of coverage if you have arthritis.
Catastrophic Health Insurance
Catastrophic health insurance plans have low monthly premiums and a very high deductible (thousands of dollars). It provides insurance coverage in worst-case scenarios, like getting seriously sick or injured. You’ll need to pay for most routine medical expenses yourself. After you meet the deductible, the plan pays allowed amounts for covered services.
People under 30 and anyone with a hardship exemption from the requirement to have health insurance can purchase this type of insurance.Pros
- Monthly premiums are low.
- Some preventive services are covered at no cost (e.g., certain vaccines and screenings for blood pressure, cholesterol, depression and diabetes).
- These plans are not suitable for people with a chronic disease or who require regular, on-going care for a health condition.
- Deductibles may be high.
Supplemental Health Insurance
This type of insurance is not designed to stand alone, but is combined with another major medical plan. It covers expenses not covered by primary insurance. This policy can be used for routine medical expenses, costs for any serious condition (like heart or bariatric surgery) or for long-term hospitalization. But you can also buy a policy to cover other expenses too – transportation, food and lodging if you have to travel far for care; childcare; and the cost of experimental treatments. How much you pay is based on what expenses you need to cover.Pros
- These plans can cover a variety of expected and unexpected expenses.
- Supplemental insurance can be expensive.
- When the policy starts paying for your care can be based on specific guidelines: disease severity, length of time in hospital, specific procedures; or it may pay less as you get older.
Taking good care of your dental health will benefit your overall health. If you have arthritis, you may be more likely to get gum (periodontal) disease. If untreated, it can result in tooth loss and major damage to the bone that supports the teeth. If you have Sjögren’s syndrome, you are more likely to have dry mouth, which can lead to cavities, mouth sores and other problems. That’s why it’s important to have dental insurance. There are three plan types:
- Dental Health Maintenance Organizations (DHMO) - These plans have a network of providers who agree to accept contracted fees. In most DHMOs, you have to choose a primary dentist and only use the dental benefits in the network. You’ll pay the lowest premiums, deductibles and copays, but covered services are more limited than in DPPOs.
- Dental Preferred Provider Organization (DPPO) – These plans have a network of providers who agree to accept contracted fees. You can choose any provider in the network and switch in-network providers at any time. Also, you can get out-of-network care, but will pay more. Your premiums and deductibles are higher than with a DMHO. You pay a percentage of the costs (coinsurance) and the plan pays the rest. But you’ll have more services covered and a larger network than with a DMHO.
- Indemnity – These plans allow you to get care from any dentist who accepts this type of coverage. Premiums are the highest and you’ll also pay a deductible. Then, you pay a percentage of the costs (coinsurance) and the plans pay the rest. You can get this coverage either through a plan offered by your employer or directly from an insurance or dental benefits company.
Taking good care of your eye health will benefit your overall health. If you have arthritis, you may be more likely to experience dry eyes or develop uveitis, an inflammatory disease that produces swelling and destroys eye tissue. This can reduce vision or lead to vision loss. A vision plan usually covers general eye health care (provided by optometrists and ophthalmologists) and eyewear (glasses and contact lens) benefits. So it’s important to find out what type of eye health conditions are covered by your major medical plan before purchasing a vision plan.
You can get this coverage either through a plan offered by your employer or directly from an insurance or vision benefits company.