Managing the Cost of a Chronic Condition: FAQ

Medically Reviewed by Sarah Goodell on September 01, 2020

Health care costs can add up quickly when you have a condition that never truly goes away, like type 2 diabetes or heart disease.

Wondering how health reform affects what's covered and what you'll pay? Here are some answers.

Will my health insurance help pay for managing a chronic condition?

Most likely. All plans sold in the Marketplace, on the individual market, or through small employers must cover a list of essential health benefits, a rule that's part of the Affordable Care Act. The exception is grandfathered plans and short-term health plans. Grandfathered plans are health plans that existed before the Affordable Care Act was signed on March 23, 2010, that have not substantially changed. Short-term health plans are those that provide coverage for less than 12 months. Large employer health plans are not required to cover the essential health benefits, but most do.

One essential benefit is management for a chronic condition, such as asthma or diabetes. Most plans will help pay for:

  • Doctor office visits
  • Lab tests
  • Prescription medicines
  • Preventive care
  • Behavioral health services
  • Rehabilitation, including physical therapyand occupational therapy
  • Hospital care


Will any plan that covers essential benefits cover the same things?

Not necessarily. Each state can make decisions about what's covered. For each benefit, states decide what specific services and level of care the plans will cover. Each health plan for sale on the state's Marketplace must cover at least what the state chose.

Here are a few ways benefits can vary between states:

  • Which medicines are covered by your plan in a specific drug class. One plan may cover many medicines to lower high blood pressure while another will only help pay for a few.
  • Only some plans cover bariatric surgery, infertility treatment, or acupuncture.

Look closely at the summary of benefits for any health plan you think you may enroll in.

How much of the costs for doctor visits and other care will my health plan cover?

That depends on what plan you choose and the specific design of the plan.

Your health plan has to limit the amount it charges you for your benefits. All plans (except those that are grandfathered) are required to limit out-of-pocket maximums to $8,150 for a single person and $16.300 for a family in 2020. 

How much of my prescription drug costs will health insurance cover?

Prescription drug coverage varies with the type of plan you have. To see exactly what a plan covers, look at its summary of benefits and coverage, and its list of included drugs.

Be aware that plans may charge a separate deductible for prescription drugs in addition to the one they have for other medical care. 

Most people will have to pay less for generic medicines than for brand-name drugs.

You probably won't pay the same amount for all brand-name drugs either. Many plans cover medicines by tiers. The higher the tier number, the more the medicine will cost you. For instance, a tier-3 medicine costs you more than a tier-1 medicine.

Take time to look at the drug formulary -- a list of prescription medicines a health plan covers -- for any plan you are considering so you can anticipate your drug costs.

How much of my drug costs will be covered if I'm on Medicare?

If you have a Medicare Part D plan to help cover the cost of your prescription drugs, the Affordable Care Act helps to lower your expenses for medicines when you are in the so-called donut hole. 

The donut hole is a gap in coverage that starts when you reach your plan's drug-spending limit. In 2020, once you and your plan have spent $4,020 on covered drugs, you're in the coverage gap. At that point, you have to pay the full cost of your medications. 

If you’re in the donut hole in 2020, you'll pay no more than 25% of the cost of drugs that are covered under Medicare Part D. 

Is there a limit on how much my health plan will pay toward caring for my chronic illness?

No. Whether you bought insurance on your own or you got it through your job, insurance companies can no longer set yearly or lifetime limits on how much they will pay toward covered essential benefits.


Will my insurance help pay for my chronic disease self-management program?

Self-management programs are covered by plans sold on the Marketplace, in the individual market, and through small employers. They are part of the essential health benefits the Affordable Care Act requires health plans to cover. Many health plans from large companies also help pay for these programs.


How can I find out exactly how much of my chronic illness treatments my plan covers?

To know for sure how much a plan covers, you can look at the plan's summary of benefits and coverage. This summary includes:

  • How much you'll have to pay for common medical services
  • Which services aren't covered by your plan
  • Details about your prescription drug coverage
  • Whether your doctors participate with the plan’s network



How else does health reform help me if I have a chronic condition?

The law also put in place these protections:

  • You have the right to appeal if a plan denies coverage for your care, including the right to appeal to someone outside your health plan.
  • Your insurance cannot be denied or dropped because you are sick or because of a pre-existing condition.
  • You cannot be charged a higher premium if you are sick or have a chronic condition.


WebMD Medical Reference



The Center for Consumer Information & Insurance Oversight: "Essential Health Benefits Standards: Ensuring Quality, Affordable Coverage."

State of Connecticut Government: "Exhibit A: Summary of Wellness, Preventive Health Care Services, and Chronic Care Management."

Families USA: "Patients' Bill of Rights: Ensuring coverage for consumers with pre-existing conditions."

Community Catalyst & Georgetown University Health Policy Institute: "Essential Benefit Package" and "Standardizing Health Plans."

Medicare Rights Center: "The Affordable Care Act: Before and After." "Services Covered and Summary of Benefits and Coverage (SBC)."

George Washington University/Robert Wood Johnson Foundation: "Chronic Disease Management."

The Center for Consumer Information & Insurance Oversight (CCIIO): "Essential Health Benefits Standards: Ensuring Quality, Affordable Coverage"

Avalere Health: "Drug Coverage in Essential Health Benefits Benchmark Plans: Formulary Analysis."

HealthConnector: Health Insurance for Massachusetts Residents. "2017-2006 Medicare Part D Standard Benefit Model Plan Parameters."

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