Health Insurance

Health Insurance, Getting Coverage, & Lupus

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Finding the perfect health insurance plan when living with lupus requires research, analysis of personal health needs, & an understanding of risk tolerances.

Health insurance (and insurance in general) works by collecting dues from members and then making payments for members that experience a qualifying event. Depending on the health insurance provider and plan, the events may vary but they often include:

  • major accidents (emergency rooms visits)
  • hospitalizations (with qualifying reason)
  • routine health check ups
  • a certain number of visits with specialty clinicians
  • laboratory and/or imaging studies
  • rehabilitation services
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From this basic premise, health insurance gets convoluted quickly. Plans can offer access to particular doctors and/or hospital systems, various cost structures to you as a patient, various payment amounts to health systems, different total risk exposure to the member, and add-ons including medication support, dental, and advanced rehab services. These are all important factors for Lupus Warriors to consider when selecting health insurance.

Comparing insurance plans isn’t exactly a fun Saturday night — but it can help you get the healthcare services you need without the risk of full financial exposure for care. Unfortunately, as many recent news stories have shared, even people with health insurance may receive bills for services provided by out-of-network providers or services that are not covered.

Speak with your lupus treatment team about insurance and pricing. There may be ways for them to help minimize cost risks, including getting prior authorizations.

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Understanding Health Insurance

If you have a full-time job, you likely already have insurance options through your employer. Talk to your HR department and learn as much as possible about what the employee health plan covers. Depending on the offerings, there may be multiple tiers offered as different price points.

Health insurance options across insurers are broken down by metal tier. The metal name is simply a way to describe the percentage range that the insurance company will pay. The 4 metals from lowest tier to highest tier are:

  • Bronze
  • Silver
  • Gold
  • Platinum

(NOTE: There is also a catastrophic plan tier. These plans are only available to people under 30 years old OR people who qualify for a hardship exemption)

Typically, the higher the metal tier, the greater percentage of costs the insurance company will pay on a bill. However, the higher metal tiers are also more expensive for you in monthly premiums.

The bolded portion above is crucial to consider when selecting a plan to make sure that you are not wasting money (paying for too high plan and not using the care) or leaving yourself vulnerable to large medical bills (paying for too low a plan).

One additional factor: If you are under 26 years old, you are able to remain on your parent’s health insurance plan as part of the 2010 Affordable Care Act (also known as Obamacare). This can be a great option if you are a student or are involved with part-time work and do not receive health benefits.

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Health Insurance Terms to Know

3 Terms relating to payments 

  1. Premiums
    • What you pay to the insurance company every month to be part of a plan. You pay this whether you use health services or not.
    • Higher premiums often mean lower deductibles and higher co-insurance amounts
    • For example: platinum plans may be expensive every month, but the deductible will be lower, meaning that insurance will begin paying sooner than a bronze plan and the insurance company would cover a larger percentage of the subsequent bills.
  2. Co-insurance (displayed as a percentage)
    • After you have paid your deductible, the insurance company begins paying. However, they often pay at a co-insurance rate. This means that the insurance company does not pay 100% of all costs after the deductible but some other agreed upon amount.
    • For example: Take a $2000 deductible and a 20% co-insurance amount. After you have paid $2000 out of pocket (plus your monthly premiums) the insurance company will begin paying. On a $10,000 hospital bill, you would pay 20% ($2,000) and insurance would pay 80% ($8,000). (Note: this is not true if you surpass your out-of-pocket maximum)
  3. Co-pays
    • After you have hit your deductible, you may still be required to pay a fixed amount ($20 for example) for some health services. These are paid at the time of the visit.
    • If you have a co-pay but have not hit your deductible, you pay the full allowable amount of the service rather than the co-pay amount.


2 terms relating to risk exposure

  1. Deductible
    • The amount of money you have to pay for covered health services out-of-pocket before the insurance begins to pay.
    • The amount you have paid into your deductible resets every year
  2. Out-of-pocket maximum/limit
    • As the name suggests, this is the maximum you can pay for covered health services in a given year. After you have hit this threshold, insurance pays for 100% of costs for covered benefits for the remained of the plan year.


Check out the HealthCare.Gov terms glossary to learn more about the relevant health insurance terms. It can make comparing health insurance plans much easier!

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Public Insurance Options

The US government offers its own insurance options, Medicaid and Medicare. As the main source of insurance in the United States is via the employer, these plans are designed to provide support to those who cannot work or have retired.

Medicaid is available to individuals or families with low income or disabilities. It pays health care providers directly and covers the services and doctors that people with lupus need. However, some services or locations might not take Medicaid. This is because Medicaid negotiates lower payments for services than other types of insurance. It can be harder to get visits with clinicians that take Medicaid and you may have to wait longer between visits. Studies have found that public options like Medicaid are effective and economical as “associated out-of-pocket spending is far lower.”

Medicare is similar to Medicaid, but it is available for older Americans age 65 and up, or for people who have had a qualified disability for more than two years. It includes vision, hearing, and dental plans, as well as somewhat more advanced access to specialists and doctors than Medicaid. There are two versions:

  • Medicare part A does is paid out of taxes and does not require a monthly payment. However, it provides less coverage and has some restrictions on services. The services that people with lupus need as they age sometimes are not fully covered by this.
  • Medicare part B requires a monthly premium or payment but provides greater coverage and services. For some people with lupus, the monthly costs can be enough to make this option not-viable.

The Children’s Health Insurance Program, or CHIP, is an alternative for children and teenagers. For children with lupus who don’t have insurance through their parents, or whose families don’t qualify for Medicaid, this option provides free or low-cost insurance and covers their medical needs.

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Buying a Health Insurance Plan

If you don’t qualify for a government plan, and you don’t have a plan through your employer, then finding the right insurance plan for you will require some additional legwork. There are many different plans, and the Affordable Care Act included a health insurance marketplace that can help narrow down those plans to the one that works best for you. The Marketplace acts as a database, a search bar, and also provides information on payment plans and services.

Pricing is developed by actuaries who forecast long-term costs for the company. To make these assessments, there are plans can only be purchased during one time frame during the year. This is called the Open Enrollment Period.

The open enrollment period often occurs in November and December. During this timeframe, you can switch health plans. After this period, you are not able to switch unless you qualify for a special exemption (which can include changing jobs, getting married, etc.)

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Doing the Research

Find health insurance that works for you AND understand the benefits that you are due. In many plans, rehabilitation services including massage and physical therapy may be covered.

When you understand what is covered, you can work with your treatment team to make choices that fit your health and economic needs. If the process of looking into insurance is boring, try to reframe it in your mind. You aren’t just looking for for insurance, you are looking for the smart choices that will give you access to the essential health services for you to feel your best (without leaving you at financial risk).

The right plan for you is out there: Lupus.org has resources for you to help you find the right plan for you. If you have health insurance but need a little more financial assistance, check out our article on disability benefits and financial aid.

Comments (3)

3 thoughts on “Health Insurance, Getting Coverage, & Lupus

  1. Yes i have recently been diagnised. With lupus autoimmune disease and nephrologic disease, im needing help getting insurance.

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