How to Choose Health Insurance for Chronic Conditions

Selecting the right health insurance plan is an important task for anyone, but getting the proper coverage is a must for those dealing with chronic conditions. The costs of managing and treating chronic diseases such as diabetes, arthritis, high blood pressure, heart disease, and more can quickly escalate without proper insurance.

Health insurance for chronic conditions is a constant dilemma for the millions of people living with long-term illnesses. However, the Affordable Care Act (ACA) passed in 2010 prevented insurers from barring coverage or charging higher rates due to preexisting conditions.

Still, finding the right health care plan to help cover care for chronic illnesses can seem like a challenge. Fortunately, there are plenty of resources available to help you make the right decision and understand the cost of specific plans.

Picking the right health insurance for chronic conditions requires people to navigate a lot of information from insurance’s essential benefits to a proper plan’s costs. Fortunately, that can be done with the right amount of time and research.

Here are some of the critical things to know when picking the right plan for you.

How can Health Insurance Help Pay For Treatment Costs of My Chronic Condition?

After lawmakers signed the ACA, the bill began to ensure that all healthcare plans on the individual market must cover a range of essential health benefits. Those essential benefits include many of the needs required to manage a chronic condition.

Most healthcare plans will cover many of the following categories:

Doctor Visits

Essential care coverage from insurance providers covers any trips to the doctor. Insurance plans cover an annual physical, but they can also help with the medical bills of additional visits to doctors and specialists associated with treating a chronic condition.

Lab Tests

Getting routine lab tests can be a necessity for monitoring some chronic conditions, and health insurance providers can cover those costs.

Prescription Drugs

Most plans can help offset the cost of prescription drugs, though the cost and coverage can vary by plan. More information on this is available below.

Preventive Care

All health insurance plans are required to cover a range of preventative services without charging a copayment or coinsurance, though eligibility for some services depends on a person’s age. Here are some examples of preventive care (see full list here).

  • Hypertension screening
  • Cholesterol screening
  • Colorectal cancer screening
  • Depression screening
  • Diabetes (Type 2) screening 
  • Lung cancer screening

Behavioral Health Services

This covers any mental health, psychiatric, marriage and family counseling, and addiction treatments, which can be done by social workers, counselors, psychiatrists, and physicians.


This includes both physical and occupational therapy. Any form of rehabilitation is considered an essential benefit for health insurance.

Hospital Care

Many chronic conditions can prompt hospital stays from time to time, which can be very costly to individuals. Fortunately, hospital care is considered an essential benefit. Therefore, insurance plans must cover hospital care.

Self-Management Programs

These educational programs were designed to teach patients suffering from chronic conditions about their illness while building their overall wellness and confidence in managing their health and leading active, engaging lives. Chronic disease management helps patients understand how to best communicate with family and healthcare professionals. They also give them tools to address the physical and psychological effects of living with a chronic disease.

Will Health Insurance Limit How Much is Covered For a Chronic Illness?

Under the ACA, health insurance providers cannot set caps on how much coverage a person is granted over the course of a year or a lifetime. If you pay for it in your plan, it will be covered. That’s one of the significant benefits of health insurance plans under the ACA. There is no limit to the amount of doctor visits or treatment.

Do You Need to Pick a Specific Type of Insurance Plan? How to Pick the Right One and Decide on a Deductible?

While most health insurance plans cover essential benefits, it’s up to each state to determine the specifics of what a plan can cover. It’s essential to understand your state’s laws, particularly how they apply to your specific condition.

Each plan is different, and that is reflected in the cost of your monthly premium. Paying a higher fee each month can help reduce any out-of-pocket expenses you could incur from healthcare providers while adding increased benefits. But health insurers are required by law to limit the annual amount charged. Insurers cannot charge Individuals more than $8,150 per year, while families cannot be charged more than $16,300. 

When it comes to deductibles, people managing chronic illnesses need to be much more aware of what they’ll need to pay out of pocket to cover treatment costs. Picking a high-deductible health plan might make sense for someone not dealing with a chronic condition, but not so much for someone who is.

A low-deductible plan will carry higher monthly premiums, but it can help make healthcare costs more predictable for people with chronic conditions. Treating those conditions usually means people will hit their deductible number each year. If the deductible is lower, less money will be coming out of pocket to cover any tests or treatments. For those with chronic conditions, insurance plans with lower deductibles can help save money in the long term.

It’s easier to estimate your medical costs and needs for people who have lived with a chronic medical condition for some time. Researching past treatments and bills from medical records from a previous year will provide an estimate of annual healthcare costs. Doing this will allow individuals to get an idea of how much coverage will be needed when picking a plan.

Many insurance companies have varying levels of coverage, and they will be able to help choose the best option to suit your needs. Taking time to fully understand the various plans and find the right one for you will save you hassle and money in the long run.

To understand what your plan covers, be sure to read the summary of the plan’s benefits. This will give you a firm grasp on what you’ll need to pay for standard medical services, what services aren’t covered, and how prescription drug payments are handled. The summary also provides information about using doctors inside and outside your network.

Will Health Insurance or Medicare Cover the Costs of Prescription Drugs?

Prescription drug coverage varies with different plans, so it’s essential to spend time researching different providers and plans to find one that will help most with offsetting the prescription cost of your specific condition. Some plans can have a separate deductible for medicine, so it’s worth watching for that when choosing a provider.  Some plans also cover generic drugs rather than brand-name medicines. 

If you have a firm idea of your prescription drug needs, it can help you choose the right plan and provider. Prescription drugs are also classified into tiers, where higher tiers lead to higher out-of-pocket costs for consumers. If you know, the medication you need falls in a higher tier, finding a plan with strong prescription coverage will be beneficial.

For those on Medicare or Medicaid, a Part D plan can reduce the costs of prescription drugs. Using this option requires paying another monthly premium on top of your typical plan premium, but it will help offset medicine costs in the long run.

What are the Barriers to Care and Finding Help?

Understandably, dealing with health insurance companies and health care providers is rarely a smooth process, and it could take some time to make sure your insurance plan covers visits and treatments with specific doctors. While it might seem like a hassle, part of dealing with a chronic illness is ironing out the details to ensure you are covered financially.

One recent survey showed one in four people avoided medical care because they were unsure if their insurance covered the cost of the treatment. That survey was not limited to people with chronic conditions, but it demonstrates just how daunting it can be to deal with the system. 

Fortunately, there are plenty of people with chronic conditions who can help others make the right decisions and find the easiest, most affordable way to handle their medical care. Organizations, such as the Diabetes Foundation, can help connect you with the right physicians and facilities to get the proper treatment under health insurance coverage, all without the significant headache.

Leaning on those organizations, friends, and family members is vital to how individuals navigate their diseases.

There are many things to consider when choosing a healthcare plan to help cover a chronic condition. From cost to coverage to convenience, it might seem like an overwhelming task to find the right plan that covers all of your medical needs without the financial burden.

But there are resources and options available that will help to navigate the complicated healthcare system. Taking the time to do the research and finding the proper plan for you will pay dividends in the long run.