RA and Health Insurance

Reviewed by: HU Medical Review Board | Last reviewed: September 2013.

The issue of health insurance is an important one for anyone with RA. Obtaining health insurance that includes hospitalization, major medical coverage, and prescription benefits is essential for any person with a disabling health condition, such as RA, because of the lifetime requirements for a variety of medical and allied health needs and the considerable cost associated with those needs.

If you live in the US, where the health insurance marketplace is particularly complex, being well informed about your health insurance options will help ensure that you and your family have both the health services and financial protection you deserve.

Understanding health insurance options

While you don’t need to be an expert when it comes to insurance, a basic understanding of some key concepts and terms will come in handy as you consider your health insurance options.

Fee-for-service versus managed care. Traditional fee-for-service health insurance plans work by allowing policy holders to obtain and pay for health services of their choice and get reimbursement by their policy provider according to the specific terms of their policy. One element of fee-for-service plans that appeals to consumers is that they allow you to choose your own provider.

Managed care health insurance plans contract with a specific network of health providers (doctors, hospitals, pharmacies, etc) that provide services to policy holders. People with managed care plans usually pay little or nothing out of pocket for services within the allowed network of providers. Health maintenance organizations or HMOs are the most restrictive type of managed care plans. In HMO plans, policy holders are strictly limited to providers and services within a specified network. On the positive side, premiums tend to be lower for these plans.

In today’s health insurance market, pure fee-for-service plans are rare, with most of these types of plans incorporating some of the limitations that come with the managed care approach to containing costs. Interestingly, one example of a pure fee-for-service plan is Medicare. Preferred provider organizations (PPOs) are hybrids of fee-for-service and managed care plans that account for most of the job-based group health insurance plans that exist today in the US. Another hybrid is that is available in some locations is the point of service (POS) plan.

How do I know what I’m eligible for?

In the past, eligibility rules for health insurance plans were typically based on eligibility criteria or rules made by the sponsor of the plan spelling out who qualified for a specific plan. With the Affordable Care Act (ACA), eligibility rules are undergoing significant changes as reforms are gradually adopted. In the US, a person can get health insurance either through the government or through a private insurance company. The tables shown below lay out the essentials on insurance eligibility by type of government and private plan.

Specific eligibility requirements for government insurance programs, which include Medicare, Medicaid, Veterans’ benefits, TRICARE, Federal Employee Health Benefits Program (FEHB), State Child Health Insurance Programs (S-CHIPs), or insurance programs for employees of state and local governments vary by program. Eligibility is determined by whether a person:

  • Qualifies for a government entitlement program, including Medicare or Medicaid
  • Was or is employed by a government agency, including the military
  • Is a family member of someone who works or worked for the government, who was eligible for such an insurance program


The main types of private health insurance plans include group coverage as a benefit of employment or membership in a union or other organization, individual plans, high-risk health insurance pools, and Medicare supplemental insurance (sometimes referred to as Medigap plans).


Government Insurance Programs

  • Source of coverage for most people 65 years or older
  • Medicare Parts A, B, C, and D, there are several options available for organizing and accessing care, including prescriptions, so it is important to get advice about Medicare options if you are eligible
  • People younger than 65 years who are disabled (including those with RA) may qualify*
  • Medical assistance entitlement program for people and families with low income, with benefits varying from state to state
  • Provides coverage for a variety of long-term care services, including stays in nursing homes
  • ACA reforms may expand eligibility
  • Coverage for children in families that do not qualify for Medicaid
VA Benefits
  • Comprehensive healthcare to veterans with service-related disabilities
  • Health benefit program for active duty and family, reserves (under certain conditions), retired military and family
  • Offers both fee-for-service and managed care plans
  • Choice of health plans for federal, non-military employees and eligible family members
  • Available from date of enrollment without restrictions
  • May continue (under certain conditions) for employee and/or eligible family members beyond retirement and death of employee
State and local government employee plans
  • Health benefit plans for employees and eligible family members

*Must meet Social Security Disability Insurance or SSDI criteria. A 24-month waiting period is required before coverage begins.


Private Health Insurance

Group health plans
  • Offered to employees and often to family members
  • Choice of different plans typically offered
  • ACA offers employers an incentive to provide insurance to employees and penalizes large employers who do not
  • Can be either fully insured or self insured
Individual and family plans
  • Purchased by individuals to cover themselves and their families
  • With ACA, these types of plans can not be denied to someone on the basis of a pre-existing condition and must be made affordable
  • Supplemental insurance that can be purchased to pay costs not covered by Medicare
State high-risk pools
  • Coverage for state residents who are uncoverable due to a pre-existing condition
  • Will be discontinued over time as ACA is phased-in and provides coverage for all patients with pre-existing conditions
  • Temporary extension of coverage for people who lose employment-group health coverage through loss of employment, divorce, retirement, death of spouse, disability, or Medicare enrollment of spouse

COBRA refers to the health benefit provisions from the Consolidated Omnibus Budget Reconciliation Act of 1985.
*It is important to find out which type applies to you and what it means for your coverage. Unlike fully insured plans, self insured plans are not regulated on a state level and this may affect you if there is a dispute concerning your legal rights as member of the plan.


RA and the Affordable Care Act

As you may know, the Patient Protection and Affordable Care Act (also referred to as the Affordable Care Act [ACA]) became federal law in 2010. Over a period of 10 years as the law is phased in, it will make a series of reforms to the health insurance system and the federal and state laws and regulations that affect that system.


How will the Affordable Care Act affect me if I have RA?

If you have RA it is important to get the facts about what the ACA means to you now and what it may mean to you in the future. Two important things that the legislation does that will affect people with RA directly are to:

  • End the annual and lifetime caps for health services that many insurance plans impose
  • Eliminate the ability of insurance providers to exclude patients due to pre-existing conditions


However, individual insurance policy plans which existed before ACA became law are now “grandfathered” plans, meaning that they are exempt from conforming to the new benefit requirements as set forth in the law. If you have a “grandfathered” plan and choose to keep that policy, your insurance plan may still impose certain limits and restrictions and you may not receive the same protections that other plans offer.

The US Department of Health and Human Services provides a website with the latest information on how the ACA may affect you.

The website for the ACA provides several useful tools, including the complete text of the ACA, a timeline of when different parts of the law are scheduled to come into effect, highlights of key features of the ACA, information on how the law is being implemented on a state-by-state basis, and a list of resources for finding out more about the ACA and getting your questions answered. Included among the key questions you can get answers to are:

  • What is the health insurance marketplace?
  • What is the marketplace in my state?
  • What if I have job-based insurance?
  • How can I get coverage at lower costs?
  • Am I eligible for Medicaid?
  • What if I have a pre-existing condition?
  • How does the healthcare law protect me?


The government is still in the process of determining what essential benefits must be covered by health plans under the new law. However, right now it appears that the ACA will require that plans cover a number of services of special importance to people with chronic diseases like RA. These include outpatient care, wellness services, substance abuse, and mental health services, prescription drugs, lab fees, and services for the management of chronic diseases, including rehabilitation services.


Arthritis Foundation resources

The Arthritis Foundation is also another great resource for the latest information about how the ACA will affect you and about issues related to health insurance in general. Check out the various educational resources, including the downloadable booklet Access to Care for Arthritis, and ACA information updates on the Arthritis Foundation website at www.arthritis.org.

The Arthritis Foundation, which was involved in lobbying efforts to influence the ACA, provides answers to some commonly asked questions about what the ACA means to people with RA, including:

  • What does the ACA do for people with arthritis?
  • Why was healthcare reform necessary?
  • How does the ACA address the needs of people with arthritis?
  • How does the ACA affect people with arthritis who are currently on Medicare?
  • How does the ACA affect people who don’t currently have insurance?
  • Overall, what should people know about the ACA?
  • What are some parts of the ACA that have not gotten publicity that people with arthritis may care about?
  • How does the ACA affect the Arthritis Act?
  • What are the priorities of the Arthritis Foundation as they relate to the ACA and health coverage?

How can people with arthritis stay up-to-date on issues and make sure that their interests are represented as the ACA is gradually implemented?

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