The condition osteoporosis is derived from Greek for “porous bones,” and results in easily acquired fractures in the hip, spine, wrists, and other areas. Over 40 million people in America currently suffer from osteoporosis or are at high risk because of their lack of bone density. Osteoporosis is much more frequently occurring in women, older individuals, and people who have a family history of the condition. It can also be caused by a number of other factors, including your ethnicity, as white and Asian women tend to have the condition more often. Low levels of estrogen in women or low testosterone in men can lead to osteoporosis, as well as a calcium or vitamin D deficiency.
Other causes may include lifestyle choices, including smoking and drinking too much alcohol, and not getting sufficient exercise. The eating disorder anorexia and the use of certain medications can also lead to osteoporosis. Osteoporosis is shows no symptoms, and is referred to as the “silent disease.” Bone can be lost without any signs, and many individuals may not be aware of their bone loss until a bump, strain, or fall results in a fracture. The disease can be diagnosed through a bone mineral density test, and treated through changes in diet, activity, and lifestyle. Medications may also be administered if necessary, but mostly the treatment involves increasing the amount of vitamin D and calcium consumed, eliminating unhealthy traits, and creating a plan for regular exercise.
Avoiding falls is another important part of preventing osteoporosis from worsening. Individuals with the disease need to take extra precautions when walking by being aware of their surroundings, wearing proper footwear, and making sure they have enough light and traction. Those with poor vision and balance, taking certain medications such as sleeping pills, and have diseases that affect walking need to be aware of their heightened risk of falling. Some individuals install bars in their homes, add more light sources, and keep phones on them in case they do fall and need to call for assistance.
Osteoporosis may result in fractures, which can be debilitating, cause chronic pain, and lead to further disability and in some cases be life-threatening. Other fractures may be asymptomatic, and only cause short term pain. Some of the more dangerous areas at risk of fracture include the spine and vertebrae, as multiple vertebrae fractures may result in loss of height, stooped posture, and chronic pain leading to restricted movement. Surgery may be required in longer bones, especially the hip, which makes osteoporosis a high-risk condition for insurance companies.
How Osteoporosis Affects Insurability
People with osteoporosis who apply for individual health insurance will most likely have to present the insurer with a bone density test in order to evaluate their level of risk. Based on each applicant’s current risk level and other health factors, their osteoporosis will be weighed according to how much health care they will require and how costly that may become. Someone who is making sure they take care of their condition by eating the right foods, getting enough calcium and vitamin D, and has not had any incidents of fracture in recent years, or at all, will likely be accepted for coverage. A more serious case is likely to experience a rate increase or a decline if their condition is severe.
Medication and surgery are also major considerations in your medical history as an applicant with osteoporosis. Rates also vary with age, as the older you become, the higher your risk for further health problems. Before you apply, it is important to assess your health, the degree to which you are helping strengthen your bones and change your lifestyle, and think realistically about your health risks. If you are aware of your current state, then you can be prepared for certain responses from the insurer, and know your rights if you are healthy and entitled to coverage. Because underwriting is known to be unjust, especially for those with conditions, it is important to find an insurer who is less strict.
One of our national health insurance companies‘ most current underwriting guidelines includes how to evaluate an applicant’s risk, and accordingly increase premiums. While no one should have to increase rates, especially at the expense of someone with a chronic condition, insurers have the right to do so. This particular carrier has less stringent rules regarding conditions, though coverage can still get too expensive or declined. Below is the risk criteria for assessing different individuals with osteoporosis. As you can see, there is a a moderate amount of variability based on personal circumstances, not all of which will cause a person to be uninsurable.
Other Sources of Coverage
In the event that you are declined for an individual health plan, or are age 65 or older, you have other options for health insurance coverage to help pay for your condition. As many individuals with osteoporosis are post-menopausal women, this disease affects a large number of elderly adults, men included. Medicare is the primary source of health insurance for this population, and Medicaid can help low-income aged persons, also. For those who are under age 65, there are several more choices for public and private health insurance. Consider all of your options as they apply to your life stage, income, employment, and health status, and decide which will be the most suitable and affordable.
The key population of individual with osteoporosis are eligible for Medicare, if they do not already have it. This is a federally funded public health insurance program with many parts, which can help cover medications, a full range of health care services, including special health needs. Regular bone density tests and a case manager or primary care doctor will likely be assigned to you to monitor your osteoporosis and make sure you are staying well. Medicare has various levels, most of which require payment, though assistance is available through Medicaid for low-income members.
If your income is less than or equal to the Federal Poverty Level and use Medicare, you may meet the Qualified Medicare Beneficiary (QMB) requirement, and Medicaid will pay your premiums, deductibles, and certain other costs. Medicare members who have an income between 101 percent and 120 percent of the FPL, they may be eligible for the Specified Low-income Medicare Beneficiary (SLMB) program. This income group can have their monthly premiums paid for by Medicaid.
Medicaid & CHIP
Medicaid covers various groups of individuals with limited means, including children, parents, pregnant women, and disabled persons. If you meet the income criteria for one of these groups and have osteoporosis, Medicaid may be available to you. In select states, Medicaid has expanded to include non-disabled adults without children, which opens up the program to a much larger portion of Americans. If eligible and approved, Medicaid will cover every necessary treatment and medication related to your condition for free or a very low cost.
The Children’s Health Insurance Program (CHIP) is an extension of Medicaid for children under age 19 and pregnant women during pregnancy. If a child’s household income is too high for Medicaid, they may qualify for CHIP, and all types of regular and specialized medical treatment will be covered. Typically, CHIP programs offer subsidized coverage with very low premiums or copayments, to children in families who earn up to 300 percent of FPL ($69,150 per year for a family of 4). Non-subsidized coverage is also available for a higher premium and higher costs to those who have incomes over 300 percent FPL.
Group Health Insurance
Those who work for an employer who offers health benefits, usually large businesses corporations, should look into obtaining coverage. Group health insurance is the most frequently used type of coverage in the nation, and a spouse and dependent children can also be added to your plan and receive the same benefits. Plans vary based on what your employer chooses to provide, though most are comprehensive, with access to all types of care. When applying, the insurance company will usually take several months to review each candidate, though you cannot be turned down for coverage based on your health.
Although employers are not fond of adding a high-risk employee to their health plan, as rates will increase for them and everyone else on the plan, they cannot decline you coverage. Therefore, the treatments and medications you need as a person with osteoporosis should be paid for. These plans tend to be HMO or POS, which is more cost-effective for everyone by utilizing the HMO network. Employees with osteoporosis should be able to find a doctor or facility within the provider network for their testing, surgery, and health care services. Always check your health plan’s benefits and provider list before obtaining a service, or choosing the plan. Making sure the services you need are covered and you are able to afford it is essential.
If your condition is severe enough to result in a decline of coverage, and you have been uninsured for at least six months, you may qualify for the Pre-Existing Condition Insurance Plan (PCIP). PCIP offers coverage without exclusions for people who have certain illnesses, and gives them access to the health care they need as soon as their benefits begin. These plans are offered in every state, and are administered by either the state or the federal government’s Department of Health and Human Services. Fees are assigned according to age and income level, but not risk or health condition.
PCIP is a temporary high-risk pool for individuals who cannot obtain health insurance on the private market, and do not qualify for Medicaid or public assistance. These plans expire at the end of 2013, as they are a precursor to the health care law accepting all individuals regardless of their health. Once the Affordable Care Act goes into full effect, the people on these plans will be able to apply for private coverage without any issues, rate increases, or exclusions.
Health Reform and Osteoporosis
The Affordable Care Act will greatly impact everyone who has a medical condition, including those with osteoporosis, as new laws will provide better access to care. Primarily, as of January 1, 2014, no insurer will be able to turn anyone away for coverage based on their health risks, increase their rates, or use elimination riders or exclusion periods. These restrictions are finally being acknowledged as discriminatory, and now all individuals will be able to purchase a health plan. Those who cannot afford a plan may be eligible for a subsidy to help them pay for insurance through an Exchange, which will be a private health plan option available through the state.
Not only will low-income Americans be able to receive coverage through subsidies, the states who get their heads on straight and take the opportunity to expand Medicaid (as it is now optional) will provide many more people with insurance, as well. Adding the category of low-income non-disabled childless adults with income up to 138 percent of the FPL would take million of people out of their uninsured state, and able to treat their condition. Medicare is also experiencing many changes under the ACA, which can be helpful in the long run. By organizing care differently, the program will attempt to give care to only when needed, while emphasizing an improvement in members’ everyday health.