How health insurance works
Here’s how health insurance helps to pay for the cost of your medical care:
Both your deductible and your out-of-pocket maximum are limits that start over with each new year. Here’s how they are different:
After you meet your deductible, the plan will pay part of the cost of your medical care for the rest of the year.
Your out-of-pocket maximum is usually much higher than your deductible. If you meet your out-of-pocket maximum, the plan will pay the full cost of your medical care for the rest of the year.
Health insurance options for people living with ALS
Private health insurance provided by an employer
You may be able to get health insurance through your employer (if you are working) or through your partner’s employer. This is called private health insurance. The cost of private health insurance plans can vary widely, so take time to shop around and compare your options.
Employers typically have an open enrollment period — a few weeks, usually in the fall, when employees are allowed to enroll in their health insurance plan or add a partner or child to their coverage. You may be able to enroll at other times of the year if you experience certain life changes, like getting married or divorced or losing health insurance coverage from another source.
COBRA continuation coverage
If you or your partner need to stop working, you will need to consider other options for health insurance coverage. COBRA continuation coverage is one option that can help you fill the gap temporarily.
With COBRA, you and your dependents can stay on your employer’s health insurance plan for a short period of time after leaving the company, typically up to 18 months. You’ll keep the exact same coverage, and if you’ve already met your deductible or out-of-pocket maximum for the year, those limits will not reset. However, your monthly premiums will cost more than they did before.
To learn more about COBRA continuation coverage, visit https://inspirafinancial.com/individual/resources-education/health-benefits/cobra-101. Keep reading to learn about long-term health insurance options.
Health insurance marketplace plans
If you are a United States citizen, you may be eligible to get health insurance through a government resource called the Health Insurance Marketplace. (The Marketplace goes by different names in different states, and you may hear it called the Exchange, too.) It’s a website where you can explore individual and family health insurance plans that are available in your state and sign up for the plan that’s right for you. Depending on your income, you may qualify for a subsidy, meaning the government will cover part of the cost of your monthly premiums.
You can sign up for a Marketplace plan during the annual Open Enrollment period each fall. You may be able to enroll at other times of the year if you experience certain life changes, like getting married or divorced or losing health insurance coverage from another source.
To explore your plan options on the Health Insurance Marketplace, visit healthcare.gov.
For step-by-step instructions on how to get health insurance through the Marketplace, check out this article: healthcare.gov/quick-guide/gettingmarketplace-health-insurance
Medicare
What services does Medicare cover for people living with ALS?
Medicare Part A
You will need the following information to apply for SSDI:
SSDI is a United States government program that provides benefits to people with disabilities. The Social Security Administration (SSA) decides if you qualify for SSDI based on your work history. SSA calculates how many “work credits” you have earned based on how long and how recently you have worked in the United States. To learn more about SSDI eligibility, visit ssa.gov/benefits/disability/qualify.html
You will need the following information to apply for SSDI:
To apply for SSDI, visit ssa.gov, call 800-772-1213, or visit your local Social Security office.
For tips on applying for SSDI, visit lesturnerals.org/3-tips-for-people-with-als-applying-for-ssdi/.
Once your SSDI application is approved, you can sign up for Medicare right away.
Medicare Part B
Medicare Part B helps to cover the cost of services including:
Medicare Part D
Medicare Part D helps to cover the cost of prescription drugs. Medicare plans that offer prescription drug coverage (Part D) are run by private insurance companies that follow rules set by Medicare.
To learn more about these plans, visit cms.gov/medicare/health-drug-plans/medicare-prescription-payment-plan.
How are home health services covered under Medicare?
Medicare Advantage
(Medicare Part C)
You may have heard about Medicare Advantage plans, also called Medicare Part C. Medicare Advantage plans usually aren’t the best fit for people with ALS because these plans often require preauthorization (meaning you and your doctor have to complete an approval process before you can get care).
Additionally, they tend to deny coverage for health care services at high rates. If the plan denies coverage for services you need, you have the right to file an appeal — but all these factors can cause delays in your care.
The process of enrolling in Medicare can be confusing. For help with navigating Medicare, contact the State Health Insurance Assistance Program (SHIP) in your state. SHIPs provide free counseling to people who are eligible for Medicare and their families and caregivers.
To find your SHIP, visit shiphelp.org.
If you choose to enroll in Medicare, signing up for a Medicare Savings Program can help you save money on health care expenses. Medicare Savings Programs help to pay for costs like your premiums, deductibles, and copays or coinsurance.
To learn more about these programs, contact the SHIP in your state. Find your SHIP at shiphelp.org.
Medicare Supplement Insurance (Medigap)
Medigap plans help to cover certain gaps in Medicare coverage, so you’ll pay less for health care services.
Here’s how it works:
Keep in mind that if a health care service is not covered under Medicare Part A or B, it will not be covered by Medicare Supplement Insurance, either.
Eligibility for Medigap plans varies based on where you live. In some states, these plans are only available to people over age 65, and they can be expensive. Search for “Medigap plans” and the name of your state to learn about your options.
Veterans’ Benefits
Additional Resources
Medicaid
If you have limited income and assets, you may be eligible for Medicaid. If you qualify, Medicaid can cover the cost of medical care that is not covered by other insurance.
Medicaid goes by different names in different states, and each state has its own requirements.
To learn more and find out if you’re eligible, search for name of your state and “Medicaid requirements.”
Learn more
My ALS Decision Tool™
ALS Learning Series
My ALS Communication Passport to Quality Care
Support Groups
Theses resources are made possible by a generous donation from the Gilbert & Jacqueline Fern Foundation and other donors to the Foundation.
