Osteoporosis and Health Insurance


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, but that cannot be held against you under health reform.


How Osteoporosis Affects Insurability: Past and Present



Health Reform and Osteoporosis

The Affordable Care Act will greatly impact everyone who has a medical condition, including those with osteoporosis, as this law provides better access to care. Primarily, as of January 1, 2014, no insurer can 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 are 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 is a private health plan option available through the state.

Not only will low-income Americans be able to receive coverage through exchanges with financial assistance, the states who have their heads on straight and take the opportunity to expand Medicaid 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 millions of people out of their uninsured state, give people the ability to treat their condition. Many states have expanded and others may elect to in the future. Medicare is also undergoing 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.



The health care law changed much about how osteoporosis is regarded by insurers. People with osteoporosis who applied for individual health insurance would 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 would be weighed according to how much health care they would require and how costly that might become. Someone who was making sure they took care of their condition by eating the right foods, getting enough calcium and vitamin D, and did not have any incidents of fracture in recent years, or at all, would likely be accepted for coverage. A more serious case was likely to experience a rate increase or a decline if their condition is severe.

Medication and surgery were also major considerations in your medical history as an applicant with osteoporosis. Rates still vary with age, as the older you become, the higher your risk for further health problems — that portion was unchanged by health reform. Before you applied, it was important to assess your health, the degree to which you were helping strengthen your bones and change your lifestyle, and think realistically about your health risks. If you were aware of your current state, then you might be prepared for certain responses from the insurer, and know your rights if you were healthy and entitled to coverage. Because underwriting is known to be unjust, especially for those with conditions, it would have been important to find an insurer who is less strict. Now, every insurer must accept you.

One of our national health insurance companies‘ 2012 underwriting guidelines included 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 had the right to do so at the time. This particular carrier had less stringent rules regarding conditions, though coverage could still get too expensive or declined. Below is their 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.



Insuring Your Condition

You cannot be declined for an individual health plan or group plan under health reform, and Medicaid and Medicare cannot turn you away if you qualify. Unless you live in a state without Medicaid expansion, there are guaranteed 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.


Individual Health Insurance

The majority of the plans we sell at East Coast Health Insurance are individual and family plans, and when you choose a policy with a robust set of benefits and a large network, you can have peace of mind knowing your bases are covered. Typically, these types of plans (comprehensive) are not the cheapest of options, but they will ultimately save you money as plans with less coverage cost you more when forced to pay most bills out-of-pocket. Whether you have three or ten insurance companies to choose from in your state, none of them can turn down your application. Therefore, you get to choose what network you join and what doctors are covered.

Your premiums can still vary by region, age and tobacco use, but your osteoporosis and gender will not affect what you pay. If a service is deemed medically necessary, you should be able to get it covered, which may still be an obstacle as doctors and insurers disagree on medical necessity at times. Nonetheless, you should at least try to get coverage, especially because being uninsured is now taxable!



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. 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, may look into obtaining coverage if it is offered. Group health insurance is the most frequently used type of coverage in the nation, and at times, your spouse and children may also be added to your plan and receive the same benefits, given the option (some plans don’t cover dependents). Plans vary based on what your employer chooses to provide, though many are comprehensive, with access to various 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.

Employer plans cannot increase rates or decline you coverage, no matter how unhealthy you might be. Therefore, many medically necessary treatments and medications you need as a person with osteoporosis should be paid for. The best plans to look for are HMO or POS, which are more cost-effective for everyone by utilizing in-network providers for a low cost. 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.