Epilepsy and Health Insurance

Epilepsy encompasses the diagnosis for many different types of seizures, recurring in individuals with the condition. It is the fourth most common neurological disorder in the country, after migraines and Alzheimer’s. Those who have been diagnosed as epileptic may have had more than one kind of seizure, but they must have had seizures more than once. Seizures are caused by abnormal electrical activity in the brain, creating an involuntary physical reaction, changing the body’s movement or function, sensation, awareness, or behavior.

Affecting about 2.3 million people in the U.S., epilepsy most commonly affects people who are very young or old. According to the Centers for Disease Control (CDC), about 10 percent of Americans will have a seizure during the course of their life, and about 3 percent will be diagnosed with epilepsy by the age of 80. Treatment for epilepsy is still  experimental, varying intensely based on the patient. Medications, such as anti-convulsants are typically prescribed for daily use to prevent seizures from recurring. Despite its prevalence and medical advancements, epilepsy remains one of the least understood major chronic illnesses.

This condition can also affect military members, as head injuries result in a condition called post-traumatic epilepsy. Brain injuries can often go undetected as they are not outwardly visible, though many soldiers have reportedly experienced seizures after contact with powerful explosions. This disorder can develop months or even years following the trauma, and result in subtle seizures accompanied by other symptoms such as memory loss and changes in behavior and/or awareness.


Treatment & Prevention

Epilepsy requires a variety of tests and treatments, all of which are a shot in the dark and will have varied results based on the patient. The most common ways to treat and monitor the condition include EEG tests, which if abnormal, will usually be an indicator of necessary follow-up. Individuals with other neurological abnormalities (typically children) are at higher risk for further seizures, the chance of which can be up to 60 percent. If the condition is proven as recurring, after three or more seizures, then a doctor will usually prescribe and anti-epileptic medication.

Ways to prevent seizures include taking prescribed medication without missing a dose, as suddenly discontinuing use could result in potentially life-threatening non-stop seizures. Also, getting a healthy amount of sleep is recommended for epileptics, in addition to being wary of alcohol and caffeine consumption. Making sure you do not mix any over-the-counter or other type of medication that could negatively interact with your anti-seizure drugs is important, as well. Still, besides medication, sleep and being careful about what you put into your body, prevention is relative to each patient.


Epilepsy and Individual Health Insurance: Past and Present


Health Reform and Epilepsy

Although in the past epilepsy was an uninsurable condition, anyone with this illness can now obtain coverage on the private individual market without rate-ups or having their benefits restricted. People who have epilepsy are also able to apply for health insurance through the state exchanges, stay covered on their parent’s plan until age 26 as a dependent and enroll in Medicaid as a childless adult in some states. One account of an epileptic young adult on Barack Obama’s Tumblr page showed that health reform had helped them stay covered for a much more reasonable cost than their individual insurance costs:

I struggled to pay astronomical insurance fees that would sufficiently cover procedures like MRIs, EEGs, an ambulance (if needed) and my two different medications. . . Because of the Affordable Care act, my dad’s company extended dependent coverage to age 26. I continued to pay insurance fees, but $300 less than I had been paying. Epilepsy isn’t nearly as terrifying as it once was when I knew I’d get a $1200 bill if I needed an ambulance.

Additionally, when this individual turns 26 and their dependent coverage expires, they can sign up for a plan with comprehensive coverage and affordable rates, especially if they do not earn enough to cover their bills. Health insurance exchanges allow people with low-to-moderate income to receive tax credits based on how much they earn to reduce premiums, and subsidies to lower medical costs on a comprehensive plan. Individual plans are also required to sell a variety of comprehensive products, as they always have, but now with more covered services, and the inability to issue elimination riders and exclusion periods. Premium rates also cannot increase based on gender or health status, only due to age and tobacco use.



The individual health insurance market was known for making it difficult for people with health problems to receive approval for coverage before the Affordable Care Act stepped in. However, underwriting varied by carrier and state. Though it would be frustrating to not know if you would be declined before applying, the possibility remained that you might not get completely locked out of the system. Insurers who accepted epileptic plan members prior to health reform may issue an exclusion period, where they will not help pay for your medications or EEG tests. Certain states can also attach an elimination rider to your plan, which established that your health plan would never cover epilepsy-related care, which was unfair and somewhat pointless for a person with epilepsy.

Fortunately, this is no longer a problem, as the health reform law has addressed declining conditions rather firmly. Anyone who has a pre-existing condition is able to purchase a plan from any insurer without exclusions or any other limits placed on their access to care. Medically necessary care may be covered by their health plan, and many basic services are now mandatory according to federal law. This holds true for the plans we sell at East Coast Health Insurance, as well as the plans on the state exchanges.

Individual and family coverage applicants were subject to exclusions, increased monthly premium rates and decline if a family member had epilepsy. Because the majority of individuals with epilepsy are children, they did have difficulty getting covered after 2010 when the law began to enforce that every insurer must accept children under 18 regardless of their health. Below is an example of the process insurance companies used to determine eligibility and pricing for a health plan applicant. This is an excerpt from a carrier’s 2012 underwriting guidelines regarding epilepsy, which indicates they would have increased rates significantly or declined an individual based on their age and the frequency of their seizures.



More Coverage Options

Although individual health insurance is always available to you, unless it is out of your price range, there are several alternatives. The most popular type of coverage in the U.S. continues to be group insurance, which is offered through an employer. Workers for large businesses with over 50 employees must have coverage offered to them under the health care law, though it may not be incredibly comprehensive or always cover dependent children or spouses. If your income is too low for any private company’s premium — group or individual — you may  qualify for Medicaid. Information on Medicaid coverage is offered through your state’s health department (or equivalent organization) as well as the public assistance section of our state pages. Those who are age 65 or older with epilepsy can receive government-funded benefits through Medicare. With the ACA in place, there will likely be a health insurance plan available to you, but certain states have made it more difficult for their residents to do so, therefore it’s unfortunately not guaranteed.


Group Health Insurance

In the event that you, your spouse, or parent(s) receive employee health benefits through the workplace, it is worth considering. Though these plans are increasing in cost over time, they continue to be the most common form of health insurance in the country. Employer-sponsored plans do not prevent anyone with a condition from obtaining coverage, and they may cover the necessary testing and prescriptions an epileptic requires to function normally depending on the insurer.

Employers typically offer HMO plans, which connect you to a specific network of providers for all of your health care services. This can be limiting in certain regions if a specialist or certain facility is needed for epilepsy tests and treatment and is not part of your HMO. If you do have access to employer benefits, make sure you review the health plan’s provider network, schedule of benefits and amount of coverage provided before you decide to enroll. Also, it is especially important for epileptics to stay covered at all times, and the waiting period imposed by group plans can last up to three months in some cases. Sign up for individual health insurance in the meantime to receive comprehensive coverage.


Medicaid & CHIP

Each state offers Medicaid and the Children’s Health Insurance Program (CHIP) for low-income children, families, pregnant women and aged or disabled persons. Some states allow childless adults with low income to enroll, as well. Income restrictions are varied in every state, though if accepted, benefits begin immediately and provide coverage for prescriptions, preventive care and all medically necessary treatment. Children up to age 18 with a family income over the limit for Medicaid can obtain coverage through CHIP, which covers the same health care services.

Medicaid also has a program called Medically Needy, for those who spend enough on health care to be considered eligible for assistance. This also varies by state, and it will provide assistance with your medical bills but not provide full Medicaid benefits or act as a comprehensive health plan.



Those who are age 65 or older are most likely aware that they have access to Medicare. Individuals with epilepsy can receive coverage for their prescriptions through Medicare Part D plans, and health care services to maintain wellness and normalcy through regular Medicare. As the Affordable Care Act also modified the Medicare system, more elderly people with epilepsy should be able to receive a better quality of care for their condition. ACOs and medical homes are attempting to streamline care for Medicare members, eliminating unnecessary treatment and keeping patients more healthy more often.



Individual Health Quotes

Medicaid Information


WebMD: Epilepsy Health Center

Epilepsy Foundation